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Guideline E5
Management of the Patent Ductus Arteriosus
V5
July 2014
July 2017
Nottingham Neonatal Service Clinical Guideline Meeting
Stephen Wardle
Consultant Neonatologist.
Nottingham Neonatal Service Clinical Guideline Meeting
Dr Stephen Wardle, Guideline Coordinator and Consultant
Neonatologist co/ Stephanie Tyrrell, Nottingham Neonatal Service
[email protected]
Nottingham Neonatal Service, Neonatal Intensive Care Units,
Midwifery Managers
Staff of the Nottingham Neonatal Service
Patients of the Nottingham Neonatal Service who fit the inclusion
criteria of the guideline below
Patent Ductus Arteriosus, Ibuprofen, Duct ligation
Risk of symptomatic PDA, risk of treatment
The contemporary evidence base has been used to develop this
guideline. References to studies utilised in the preparation of this
guideline are given at its end.
Clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior
colleague. Caution is advised when using guidelines after the review date. This guideline has
been registered with the Nottingham University Hospitals NHS Trust.
SUMMARY
In Nottingham a conservative approach to symptomatic treatment is used.
This means:
• Only consider treatment in babies with a clinically important symptomatic PDA
(see below)
• Routine echo on all asymptomatic babies is not performed to guide treatment
• An echo should always be performed in babies before considering treatment (see
echo indicators of significance below).
• Ibuprofen rather than Indometacin is used because the adverse effects are fewer,
in particular the decreased risk of renal impairment and reduced incidence of NEC
with ibuprofen [14].
• Consider duct ligation if other treatment options (general or specific) have failed
and the PDA is felt to be significantly contributing to a baby’s problems
1. Introduction and Background
In preterm babies, closure of the ductus arteriosus (DA) may be delayed after birth and is
influenced by a number of factors such as gestation at birth, Respiratory Distress Syndrome
(RDS), artificial mechanical ventilation, infection and lack of antenatal steroid treatment.
These risk factors are more common amongst babies who require intensive care [1].
Persistent patency of the DA is therefore common in preterm infants; in over 50-60% of
babies born at less than 29 weeks gestation the DA does not close spontaneously. This is
known as a patent ductus arteriosus (PDA).
The presence of a PDA may result in a shunt from the left to right (aorta to pulmonary artery)
which develops in the early newborn period. This may result in:
Nottingham Neonatal Service – Clinical Guidelines
•
•
Guideline E5
increased pulmonary blood flow
This may lead to increasing respiratory distress with ventilator dependence, increasing
ventilator requirements, respiratory acidosis, pulmonary haemorrhage and chronic lung
disease.
reduced systemic blood flow
This may lead to hypotension, cerebral and mesenteric ischaemia, necrotising
enterocolitis and severe intraventricular haemorrhage.
The evidence for treating and not treating the PDA has been summarised in numerous
systematic reviews and review articles [2-7] therefore all of this information will not be
reproduced here.
Based on this evidence there are arguments in favour of and against treating the PDA
aggressively. In summary these are:
For Treatment
PDA in the preterm infant has been associated with significant morbidities, including higher
rates of chronic lung disease, hypotension, pulmonary haemorrhage, intraventricular
haemorrhage, and necrotising enterocolitis (NEC) and increased mortality [8,9]. Treating
the PDA can reduce the need for surgical closure and has been shown to decrease some
short term adverse effects such as significant pulmonary haemorrhage and IVH [10,11].
Some of these studies have not demonstrated long term benefits of treatment but this may
be because (in the case of the TIPP study of prophylactic indomethacin [12]) the population
treated were unselected other than by birth weight and the risks and complications of
treatment may mask any of the potential benefits in babies who were at low risk of
complications.
Proponents of treatment therefore argue that for an individual baby targeted treatment of
those babies with the most significant ducts may be of benefit rather than prophylactically
treating all babies of a particular birth weight or gestation. Waiting for clinical symptoms
from the PDA may result in complications having already occurred before treatment is given.
Future studies (Baby Oscar study) [13] hope to try to answer this question and until more
research is available many clinicians continue to treat PDA with Ibuprofen and, or surgery.
Against Treatment
The presence of a PDA may be a sign of other problems rather than the cause of them.
Most studies into the PDA and its treatment, particularly older studies, concentrated on the
short term effects of the treatment and have mostly not studied or recorded long term
effects. This has meant that despite demonstrating that ductal closure is possible with
various different approaches, and reduces the need for surgical ligation, studies have not
demonstrated long term benefits of these treatments [10,14,15,16]. Even those studies
which have looked at long term outcomes have failed to demonstrate differences in
important outcomes such as the rate of chronic lung disease, mortality or
neurodevelopmental problems despite a higher rate of duct closure in the treatment group
[10]. This implies that the presence of a PDA is not the cause of these complications but
merely a co-morbidity and attempted treatment (which may have significant adverse effects)
is futile and may even be harmful. Many therefore argue that the PDA should not be treated
or should only be treated when significant complications occur [5].
2. Treatment Options
There are three recognised approaches for medical management of PDA:
1.
Prophylactic treatment (commencing treatment in all babies within 24 hours of
birth)
Nottingham Neonatal Service – Clinical Guidelines
Guideline E5
Prophylactic treatment with indomethacin has been studied extensively. The TIPP study
was a large multicentre randomised controlled trial powered to look at long term outcomes
[12]. This study reported significant reduction in IVH and PDA in extremely low birth weight
babies including a 50% reduction in the need to carry out surgical ligation with no major
early adverse effects of treatment but failed to show improvement in the primary measure of
long-term neurodevelopmental outcome or mortality. In addition there were no differences in
the rate of chronic lung disease or death. i.e. when prophylactic indomethacin is used fewer
babies require a duct ligation but this does not affect the longer term outcomes of CLD,
death or neuro-disability.
Ibuprofen has not been studied as prophylaxis in studies as large as this. A recent metaanalysis of prophylactic treatment with ibuprofen reported significant decrease in the
incidence of PDA on day three compared with controls [RR 0.36 (95% CI 0.28, 0.46); NNT
4]. In this cohort, the PDA had closed spontaneously by day three in 58% of the neonates in
the control group and there were no differences in complications of prematurity between the
two groups [16].
Prophylactic Indometacin treatment was used in Nottingham on the basis of reducing the
need for surgical duct ligation but was stopped in 2009 when the supply of Indometacin was
stopped. Since there are no long term data on prophylactic Ibuprofen this has not been
used for prophylactic treatment.
2. Symptomatic treatment (commencing treatment only when PDA is
symptomatic, usually after 72 hours).
Treatment with either Ibuprofen or Indometacin in symptomatic babies closes the duct when
compared with placebo. The Cochrane meta-analysis shows no difference observed in the
failure rates of treatment between ibuprofen and indomethacin. There is no difference in
mortality, IVH, or chronic lung disease when Indometacin is compared with Ibuprofen.
Ibuprofen, however, significantly reduced the incidence of NEC (RR 0.68 (95% CI 0.47,
0.99) [14] when compared with Indometacin and has less effect on serum creatinine / renal
output. None of the treatment studies though, have been powered to look at long term
effects of treatment. In addition this approach is criticised because symptoms and clinical
signs of a PDA are not sensitive and specific markers of the presence of a large PDA on
echo [17]. As a result it is essential to perform an echo when a significant PDA which might
require treatment is suspected before treatment is considered.
3. Targeted early treatment of an asymptomatic PDA (Identifying large PDA
before it is symptomatic and commencing treatment, usually between 6-72 hrs).
This approach is favoured by some as only babies with the highest risk of complications will
be exposed to treatment, however, it requires an early echo in all babies to identify which
babies are at most risk. There have been fewer studies of this approach. A recent study
from Australia was unfortunately stopped early due to lack of availability of indomethacin. It
showed a decrease in early pulmonary haemorrhage but there were no differences in deaths
and the study was unfortunately underpowered to show longer term differences [11].
3. Patient Selection – who to treat
In Nottingham a conservative approach to symptomatic treatment is used.
This means:
• Only consider treatment in babies with a clinically important symptomatic PDA
(see below)
• Routine echo on all asymptomatic babies is not performed to guide treatment
• An echo should always be performed in babies before considering treatment
(see echo indicators of significance below).
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•
Guideline E5
Ibuprofen rather than Indometacin is used because the adverse effects are
fewer, in particular the decreased risk of renal impairment and reduced
incidence of NEC with ibuprofen [14].
Consider duct ligation if other treatment options (general or specific) have
failed and the PDA is felt to be significantly contributing to a baby’s problems
3.1 What is a Clinically Important PDA?
There may or may not be clinical signs and symptoms attributable to a PDA such as a
murmur, bounding pulses, wide pulse pressure etc but do not rely on these signs to guide
treatment (or investigation) as they do not necessarily correlate well with the clinically
important effects and significance of a PDA as this is also dependent on the baby’s ability to
compensate. However these signs are useful to highlight the presence of a PDA whose
significance can then be assessed.
Presence of a PDA may be associated with:
• A baby remaining ventilator dependent beyond 1 week of age
• Increasing ventilator or oxygen requirements without another obvious cause (for
example airway problems, infection or pneumothorax)
• Significant hypotension with no other obvious cause
• Significant pulmonary haemorrhage
• When there is abdominal distension or suspected NEC
• A baby remains ventilator dependent and post-natal steroids are being considered to
try to achieve extubation.
In general babies who are stable on CPAP with low oxygen requirements / those in
nasal oxygen should not be considered for treatment.
An echo should be performed in these circumstances if there are significant clinical signs to
look for a PDA but it is also possible to have no / few clinical signs and still have a significant
PDA [17].
Performing an echo in a baby with clinical signs of a PDA who is stable and not in need of
treatment (assessed clinically) is only useful to exclude structural heart disease because a
PDA on echo alone should not prompt treatment when the baby is stable and well.
3.2 Role of Echocardiography for PDA
Echocardiography is used both to exclude congenital structural heart disease and to assess
the PDA and its significance based on several criteria. However, assessing a PDA using
echocardiography is not straightforward as there is no single measurement which accurately
reflects the haemodynamic significance of a PDA or its likely effects on the baby. The
assessments which can be made are ductal diameter [18-20], ductal flow pattern [21],
LA:Aortic root ratio [22] and retrograde post ductal aortic diastolic flow [23] and effects of the
PDA on flow to other organs.
It is clear from the literature that none of these echo assessments is perfect as they are all
operator dependent and none of them directly reflects the haemodynamic significance of a
PDA. Many therefore recommend that several of these measures should be used together
to make an assessment of what is a significant PDA without relying on any one individual
measurement which might be open to error [25]. The following is a reasonable guide to
identifying an ‘echocardiographically significant’ PDA:
•
•
•
•
Diameter of >=2.0 mm
Pulsatile ductal flow pattern
Left heart dilatation (LA/Ao >=1.5)
Retrograde post-ductal aortic diastolic flow
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Abnormal diastolic mesenteric or cerebral flow
Not all of these criteria are required to justify treatment but the presence of 2 or more of
these features helps to assess the significance of the PDA. McNamara et al have published
a grading system to help make this clinical decision based on clinical severity
(asymptomatic, mild, moderate severe) and echocardiographic significance (no PDA, small
non-significant, moderately haemodynamic significant, large haemodynamically significant)
[25]. This approach may be helpful but there is currently no published data to demonstrate
how this affects the number which require treatment or whether it improves outcomes.
4. Management of the Baby with a PDA – how to treat.
4.1 Fluid Management and Diuretic Treatment
If there is evidence of a high preload (cardiomegaly, dilated LA, large La:Ao ratio) then
consider using diuretics (always check electrolytes within 48 hours after commencing
diuretics). Also consider restricting the IV fluid intake to 120 ml/kg/day but ensure that
nutrition is not compromised in doing this by using a more concentrated regimen of
parenteral nutrition if necessary (see Neonatal Guideline D6). Do not restrict oral intake
unless it is excessive as this will compromise nutrition. There is no evidence that the use of
diuretics or restricting fluid helps to close the PDA but they may be of symptomatic benefit
and render treatment with ibuprofen unnecessary.
If the duct is considered clinically significant and there are echo features of a significant duct
and there are no contraindications then consider using Ibuprofen treatment.
4.2 Ibuprofen Treatment (see Ibuprofen monograph in Neonatal Pharmacopoeia)
Prostaglandin synthetase inhibitors promote duct closure by the normal postnatal
mechanism. Indometacin and Ibuprofen have been widely used for over many years in
neonatal care. Although they have side effects, these are usually not common or serious.
The effects are:
• Duct closure in 70-80% infants [14]. Closure is sometimes only temporary and repeated
treatment may be necessary but the success rate is likely to be higher with the first
course of treatment when given in the early newborn period. Treatment may be less
successful beyond 2 weeks of age and this may be partly because of the drug availability
but there is no evidence that treatment will not work later.
• Reduced systemic blood flow. This is the result of its vasoconstrictor action and may
explain the reduction in severe IVH when Indometacin is used prophylactically. They
also reduce mesenteric blood flow although there is no good evidence to link their use
with NEC.
• Gastric bleeding may rarely occur
• Impaired renal function from inhibition of renal prostaglandin synthesis. Ibuprofen
results in a fall in urine output by 24 hours and this persists for several days. Creatinine
rises and sodium falls. Ibuprofen has been shown to be as effective as indomethacin for
duct closure but the renal effects are considerably less [14].
In babies on Ibuprofen always check electrolytes and platelets daily and carefully assess
and manage fluid balance.
After treatment a repeat echo should be performed to confirm closure particularly if there is
not a significant improvement in clinical status.
4.2.1 Relative Contraindications
• Thrombocytopaenia (platelet count <50)
• Evidence of significant GI haemorrhage
• Significant renal impairment (creatinine >100)
• Pulmonary hypertension. Ibuprofen may cause or exacerbate pulmonary hypertension
• Other congenital heart lesions which may be duct dependent
Nottingham Neonatal Service – Clinical Guidelines
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4.3 Surgical closure of a PDA
This should only be considered in babies with:
• A clinically significant PDA (as defined above)
• Echocardiographic signs of a significant duct (as defined above)
• A PDA which has failed to close despite two courses of Ibuprofen and / or baby is
beyond 4 weeks of age when ibuprofen may be less effective
This decision is made by the Consultant Neonatologist. When considering surgical closure
discuss the baby with the Cardiology / Cardiac Surgical teams from the Cardio-Thoracic
Centre. Also have early discussions with the transport team as organisation of a ‘drive
through’ PDA ligation is logistically difficult from a transport perspective. Usually at least 48
hours’ notice is required.
Check lists for PDA ligation are available and need to be completed before referral of the
patient to the cardio-thoracic centre and CenTre. This is attached as an Appendix.
4.3.1 Post Op Care
Following PDA ligation babies are frequently unstable form a cardiorespiratory point of view.
These are often babies who have been ventilator dependent or had high oxygen
requirement pre-operatively and post-op deterioration is frequent so senior involvement with
their early post-op management is essential. It is important that they are not transported
until stable.
Hypotension, low cardiac output and increased ventilator requirements are frequent. The
causes of this instability may include altered preload due to hypovolemia or lung
overexpansion, left ventricular dysfunction associated with reduced preload and increased
afterload, mechanical causes (e.g., pleural effusion) or adrenal insufficiency.
As a result the cardio-respiratory support should be carefully considered in the post-op PDA
ligation patient. Echocardiography may help to guide treatment [26].
The following are important:
• Optimise ventilaton – achieve adequate oxygenation and CO2 clearance but try to
avoid high ventilator pressures where possible. Consider using HFOV is ventilator
requirements are high. (see Neonatal Guideline B1 Ventilation Guideline)
• Monitor and optimise perfusion. Invasive BP measurement is very helpful. Inotropes
rather than additional volume are more likely to be helpful. Avoid high dose
dopamine (>10 micrograms/kg/min) as this may decrease left ventricular output. The
use of Milrinone has been described [27] as being helpful, as has hydrocortisone in
some babies. (see Neonatal Guideline E2 Monitoring and management of
hypotension / cardiovascular support)
• Optimise haemoglobin concentration (see Neonatal Guideline E1 Red Cell
Transfusion Guideline)
• Careful monitoring of fluid balance and urine output
Babies are usually transferred back with a chest drain in place. There should be a surgical
plan for the management of this drain and its removal should be discussed with the
cardiothoracic surgeon.
4.3.2 Post-Op Complications
Surgery related complications include: intra-operative bleeding, pneumothorax, vocal cord
paralysis, chylothorax, and phrenic nerve injury. The collective incidence of these
complications is usually low.
Nottingham Neonatal Service – Clinical Guidelines
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In a series of 125 babies from Scotland, after duct ligation (median gestational age 26
weeks (IQR 25–27 weeks), median birth weight 840 g (IQR 730–1035 g)), the 30-day and 1year mortality rates were 4.8% and 12.8%, respectively, with neuro-disability in 32% of
survivors. Babies were extubated after a median of 5 days but 36% required corticosteroids,
46.8% went home on oxygen and 4.8% had a post-op vocal cord palsy [24].
5.
•
•
•
•
•
Audit Points
Indications for treatment with ibuprofen
Numbers of babies given treatment over time
Indications for duct ligation
Outcomes from duct ligation
Use of Inotropes (Milrinone)
Summary of Evidence
Clinical signs of a PDA are not good
indicators of a clinically significant PDA
Treatment with Ibuprofen is effective at
closing the PDA
Early / prophylactic treatment may reduce the
risk of pulmonary haemorrhage and IVH
Treatment with Indometacin or Ibuprofen has
not been shown to effect long term outcome
(chronic
lung
disease,
death
or
neurodevelopmental outcome).
Ibuprofen is associated with few adverse
effects than Indometacin
Level of Evidence
C
A
A
A
A
6. References
1. Hamrick SE, Hansmann G. Patent ductus arteriosus of the preterm infant.
Pediatrics 2010;125(5):1020-30.
2. Noori S. Patent ductus arteriosus in the preterm infant: to treat or not to treat? J
Perinatol 2010;30 Suppl:S31-7.
3. Clyman RI, Chorne N. Patent ductus arteriosus: evidence for and against treatment.
J Pediatr 2007;150(3):216-9.
4. Bose CL, Laughon MM. Patent ductus arteriosus: lack of evidence for common
treatments. Arch Dis Child Fetal Neonatal Ed 2007;92(6):F498-502.
5. Benitz WE. Patent Ductus Arteriosus: to treat or not to treat? Arch Dis Child Fetal
Neonatal Ed
6. Heuchan AM, Clyman RI. Managing the patent ductus arteriosus: current treatment
options. Arch Dis Child Fetal Neonatal Ed fetalneonatal-2014-306176
doi:10.1136/archdischild-2014-306176
7. Smith CL, Kissack CM. Patent ductus arteriosus: time to grasp the nettle? Arch Dis
Child Fetal Neonatal Ed 2013;98:3 F269-F271
8. Dollberg S, Lusky A, Reichman B. Patent ductus arteriosus, indomethacin and
necrotizing enterocolitis in very low birth weight infants: a population-based study. J
Pediatr Gastroenterol Nutr 2005;40:184–8.
9. Rojas MA, Gonzalez A, Bancalari E, et al. Changing trends in the epidemiology and
pathogenesis of neonatal chronic lung disease. J Pediatr 1995;126:605–10.
10. Fowlie PW, Davis PG, McGuire W. Prophylactic intravenous indomethacin for
preventing mortality and morbidity in preterm infants. Cochrane Database of
Systematic Reviews 2010;7:CD000174.
Nottingham Neonatal Service – Clinical Guidelines
Guideline E5
11. Kluckow M, Jeffery M, Gill A, et al. A randomised placebo-controlled trial of early
treatment of the patent ductus arteriosus Arch Dis Child Fetal Neonatal Ed
2014;99:F99–F104.
12. Schmidt B, Davis P, Moddemann D, et al. Long-term effects of indomethacin
prophylaxis in extremely-low-birth-weight infants. N Engl J Med 2001;344:1966–72
13. Does selective early treatment of foetal shunt (patent ductus arteriosus) in extreme
preterm infants reduce the complications and improve their long term outcome?
(OSCAR
trial).
ISRCTN84264977.
http://www.controlledtrials.com/isrctn/pf/84264977
14. Ohlsson A, Walia R, Shah SS. Ibuprofen for the treatment of patent ductus arteriosus
in preterm and/or low birth weight infants. Cochrane Database of Systematic
Reviews
2013,
Issue
4.
Art.
No.:
CD003481.
DOI:
10.1002/14651858.CD003481.pub5
15. Cooke L, Steer P, Woodgate P. Indomethacin for asymptomatic patent ductus
arteriosus in preterm infants. Cochrane Database of Systematic Reviews 2003
http://www.nichd.nih.gov/cochrane_data/cookel_01/cookel_01.html
16. Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in
preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews
2011, Issue 7. Art. No.: CD004213. DOI: 10.1002/14651858.CD004213.pub3.
17. Davis P, Turner-Gomes S, Cunningham K, Way C, Roberts R, et al. Precision and
accuracy of clinical and radiological signs in premature infants at risk of patent
ductus arteriosus. Arch Pediatr Adolesc Med 1995;149:1136-1141
18. Evans N, Iyer P. Longitudinal changes in the diameter of the ductus arteriosus in
ventilated preterm infants: correlation with respiratory outcomes. Arch Dis Child Fetal
Neonatal Ed 1995;72:F156–61.
19. Evans N. Current controversies in the diagnosis and treatment of patent ductus
arteriosus in preterm infants. Adv Neonatal Care 2003;3:168–77.
20. Kluckow M, Evans N. Early echocardiographic prediction of symptomatic patent
ductus arteriosus in preterm infants undergoing mechanical ventilation. J Pediatr
1995;127:774–9.
21. Su BH, Watanabe T, Shimizu M, Yanagisawa M. Echocardiographic assessment of
patent ductus arteriosus shunt flow pattern in premature infants. Arch Dis Child Fetal
Neonatal Ed 1997;77(1):F36-40.
22. Iyer P, Evans N. Re-evaluation of the left atrial to aortic root ratio as a marker of
patent ductus arteriosus. Arch Dis Child Fetal Neonatal Ed 1994;70:F112–7.
23. Groves AM, Kuschel CA, Kight DB, Skinner J. Does Retrograde Diastolic Flow in the
Descending Aorta Signify Impaired Systemic Perfusion in Preterm Infants? Pediatr
Res 63:89–94, 2008
24. Heuchan AM, Hunter L, Young D. Outcomes following the surgical ligation of the
patent ductus arteriosus in premature infants in Scotland. Arch Dis Child Fetal
Neonatal Ed 2012;97:1 F39-F44
25. McNamara PJ, Sehgal A. Towards rational management of the patent ductus
arteriosus: the need for disease staging. Arch Dis Child Fetal Neonatal Ed 2007 92:
F424-F427
26. Jain A, Sahni M, El-Khuffash A, Khadawardi E, Sehgal A, McNamara PJ. Use of
Targeted Neonatal Echocardiography to Prevent Postoperative Cardiorespiratory
Instability after Patent Ductus Arteriosus Ligation. J Pediatr 2012;160:584-9
27. Sehgal A, Francis JV Lewis AI. Use of Milrinone in the management of
haemodynamic instability following duct ligation. Eur J Pediatr (2011) 170:115–119
Nottingham Neonatal Service – Clinical Guidelines
Guideline E5
Appendix 1 CenTre Neonatal Transport
Glenfield PDA Checklist
The referring unit team MUST complete ALL sections
Name
DoB
Hospital No.
Age
NHS No.
Please contact CenTre Neonatal Transport on 0300 300 0038 as soon as possible to
arrange transfer for surgery. Normally 48 hours notice is required.
Actions to be completed by referring unit before referral
to CenTre
Infant has been disused with
–
Neonatal Consultant at Network Lead Centre
–
Paediatric Cardiothoracic Surgeon at Glenfield
Referrers to sign to
confirm completed
Date
completed
A referral letter has been faxed to the above surgeon
*Date transfer required
*Date of operation
*Time infant to be at Glenfield
MRSA swab required within 7 days prior to surgery
Date of last swab
Result
Parents
– Who will give consent
– How will they get to Glenfield
CenTre may not be able to accommodate parents in the ambulance –
alternative arrangements will need to be made if parents do not have
their own transport.
* All timings must be discussed with CenTre Neonatal Transport at referral to ensure
appropriate. Arrangement of date and time of the operation is the responsibility of the
referring unit.
Please turn over for pre departure checklist. This should be completed the day before
the transfer to ensure a prompt departure on the day of the operation.
CenTre Neonatal Transport staff have their own checklist to ensure everything is
completed prior to leaving your unit.
Nottingham Neonatal Service – Clinical Guidelines
Guideline E5
This should be started the day prior to the transfer & completed prior to leaving the
referring unit
Actions to be completed by referring team prior to arrival
of CenTre team
An up to date clinical summary letter printed
EITHER
– A complete photocopy of the relevant medical notes
inc latest results etc
OR
– An agreement for CenTre to take the infants medical
notes with them
Maternal blood sample
– Adult bottle (7.5mls EDTA KE for transfusion)
–
Maternal details handwritten on bottle
– A blood transfusion form
TWO correct name bands on infant
At least TWO working cannulae in place
Less than 2 hours before CenTre team arrive
–
Recent blood gas taken and results recorded
–
BP measured and recorded
– Axilla temperature taken and recorded
All results from previous 12 hours to be available
– FBC, U&E, CRP, Clotting
* Hb at acceptable level pre transfer – clarify with Glenfield
IV opiate infusion running before team arrive if ventilated –
check prescription and syringe label
IV maintenance fluids correctly labelled in 50ml syringes
Routine / regular medications given as prescribed before
departure
Drug chart or copy to go with infant
X-rays available on disc to accompany infant if PACS not
an option
Referrers to sign to
confirm completed
Date
completed
Nottingham Neonatal Service – Clinical Guidelines
Guideline E5
The table below shows where the responsibility for a task being completed lies
Task
Referring Unit Responsibility
Discussion with network
lead and cardiac
surgeon + referral faxed
to Glenfield
Arrange date & time of
operation
Prior to contacting CenTre
Recent MRSA swab
Parents transport to
Glenfield
PDA checklist
commenced
Appropriate copies of
notes, results drug
charts, x-rays etc
Appropriate blood
samples, documentation
Infant correctly
identified
Working IV access
Recent observations
documented
Prior to contacting CenTre
Prior to contacting CenTre
Arrangements made for parents to
get to Glenfield before contacting
CenTre
Prior to contacting CenTre
CenTre Transport
Responsibility
To check at referral
To check at referral, if not
achievable contact Transport
Consultant via conference call to
discuss
To check at referral
To check arrangements made at
referral
All copies made before transport
team arrive
To check unit has started their
copy and to commence CenTre
copy at referral
To check and ensure all taken
with infant
Before transport team arrive after
discussion with Glenfield surgeons
ID labels in situ before transport
team arrive
To ensure all transferred
appropriately with the infant
To check infant is correctly
labelled
Inserted and patent before
transport team arrive
Recorded before transport team
arrive
To confirm access is patent before
leaving referring unit
Confirm and document infants
clinical condition before leaving
referring unit
To check prescription and syringe
label are correct. To ensure infant
settled on infusion before leaving
referring unit
To check prescription and syringe
label are correct before leaving
referring unit. To assist referring
team to draw up if necessary
To ensure all medications have
been administered as prescribed.
To check if any due during the
time the transport team have
responsibility for infant and to take
with the infant as necessary
Ventilated infant
receiving opiate infusion
Infusion prescribed, drawn up and
running before transport team
arrive
Maintenance fluids in
50ml syringes
Infusions to be either swapped or
made up in 50ml syringes before
transport team arrive
Regular medications
given as prescribed
To ensure all prescribed
medications are given as
prescribed before transport team
arrive
11