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Nottingham Neonatal Service – Clinical Guidelines Title: Version: Ratification Date: Review Date: Approval: Author: Job Title: Consultation: Guideline Contact Distribution: Target audience: Patients to whom this applies: Key Words: Risk Managed: Evidence used: 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). Nottingham Neonatal Service – Clinical Guidelines • • 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 Nottingham Neonatal Service – Clinical Guidelines • Guideline E5 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 Guideline E5 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 Guideline E5 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