新生儿转运研究进展

危重新生儿转运病死率高,为降低病死率应提前判断转运指征,此外还需有产业化的转运人才培养、多种职业联合的转运团队、统一标准的转运设备等作保障.该文主要从新生儿转运的教育培训、团队、设备、指征、最新技能及空中转运等方面进行综述.     

Pediatric Critical Care Interfacility Transport

The interfacility transport of critically ill and injured children can be safely performed by pediatric transport services. Specially trained transport staff, armed with appropriate equipment and medications and guided by off-line protocols and on-line medical control, provide a vital service for these children, facilitating timely access to tertiary care. Transport team members are trained to provide this specialized care in various environments, including ambulance, rotor wing, and fixed wing aircraft. Team training, continuing education, and quality improvement processes assist in further refining the skills and practices of the team members. Pediatric transport teams provide a unique service for these children and their families.     

Setting up a neonatal transport service: Air transport

Air transport is an integral part of any system that provides neonatal care in the developed world. To ensure that this is developed in an efficient and appropriate manner a prospective analysis is required to allow a multidisciplinary team to progress a project aimed at providing appropriate staff with adequate training using equipment that has satisfied all regulatory bodies.This article highlights the difficulties in achieving this, reflecting on the way in which established air transport teams have overcome many of the difficulties.The commonalities with land based transport are emphasised along with those issues which are specific to teams providing such a service who aspire to become “air capable”.     

远距离院际转运507例危重症患儿回顾性分析

目的 提高危重症患儿的远距离院际转运水平.方法 回顾性分析2009年8月至2011年7月广东省人民医院PICU通过远距离院际转运收治的507例危重症患儿的临床资料、诊断和转归.结果 507例危重症患儿中,男336例,女171例;年龄29 d ～15岁(中位数11个月);体质量2.5 ～80.0 kg(中位数8.0 kg);转运花费时间为90 ～ 990 min(中位数为264 min),其中121例(23.9％)花费121～240 min,288例(56.8％)花费241 ～480 min,72例(14.2％)花费超过480 min;转运距离为74～ 620 km(中位数266 km),其中249例(49.1％)患儿转运距离101 ～ 200 km,133例(26.2％)患儿转运距离≤100 km.前3类疾病是心血管系统疾病(169例,33.3％)、呼吸系统疾病(128例,25.2％)和神经系统疾病(85例,16.8％);转运过程中无一例死亡,均入住广东省人民医院PICU进一步诊断和治疗,其中治愈出院486例(95.9％),放弃治疗13例,死亡8例.结论 在院际远距离转运时,配备专业的转运队伍,做好转运前充分的准备,密切监护患儿在转运途中的病情变化能有效提高转运质量.     

Characteristics of travel to and from school among adolescents in NSW, Australia

AIM: Active transport to and from school is frequently identified as an opportunity to increase energy expenditure among young people. The epidemiology of travel behaviours among Grade 6, 8 and 10 students in NSW is reported. METHODS: A representative population survey of students in NSW, Australia was conducted during February to May 2004 (n = 2750) and the prevalence of travelling to and from school by walking, car and public transport was determined for Grade 6, 8 and 10 students. RESULTS: Among Grade 6 students, approximately 30% travelled by car, 30% walked and 20% used public transport to travel to school (the travel habits of 20% could not be accurately characterised). Among secondary school students, approximately 50% used public transport, 15-20% travelled by car and 15-20% walked. Among those who walked or used public transport, the median times spent walking were 10-15 min and 5 min per trip, respectively. CONCLUSIONS: While there is little scope to increase the prevalence of active transport among secondary school students, there is potential to do so among primary school students. Primary school students who replace travelling to and from school by car with walking will experience an increase in activity energy expenditure of up to 10% and those who change to public transport will experience an increase in activity energy expenditure of up to 3%.     

Audit of neonatal intensive care transport–closing the loop

To audit the effectiveness of changes in transport arrangements, data on babies ventilated during transfer into a neonatal unit were compared between two periods. During the first period, August 1991 -February 1993, an ad hoc transport team operated. Transport practice was changed in 1993 by forming a nine-person nursing transport team, improving training and upgrading monitoring. The second audit period was January 1994-July 1995. The groups were not significantly different for birth weight, gestation or levels of ventilation. Physiological variables were assessed with a "transport score". Improved scores for temperature and pH were achieved on completion of transfer in 1994–95 compared to 1991–93. Stabilizing prior to transfer took longer in the 1994–95 period. No serious deteriorations occurred in transit in the 1994–95 period, three in 1991–93. Audit facilitates identification of problems in transport. Staff, education and equipment changes were associated with improved audited outcomes.     

Recomendaciones sobre el perfil de competencias y estándares del sistema de traslado neonatal en España

The first hours of life of a sick or premature newborn are crucial for its prognosis and therefore delivery should take place in a center prepared for that degree of complexity. When this condition is not met, the newborn must be transferred in an optimal and safe way to the center that can offer the necessary care. The training, staffing, organization and coordination of the neonatal transport team are essential to guarantee a safe transfer. Being aware of the interest and the advances that are currently taking place in this area of pediatrics, the Standards Commission and the Neonatal Transport Commission of the Spanish Society of Neonatology have prepared this document. In it, both the provision of human and material resources necessary as well as the bases of clinical stabilization in transport to carry out the neonatal transfer in a safe way and proportionate to the needs of the critical newborn have been exhaustively reviewed and detailed.     

Rab proteins and Rab-associated proteins: major actors in the mechanism of protein-trafficking disorders

Ras-associated binding (Rab) proteins and Rab-associated proteins are key regulators of vesicle transport, which is essential for the delivery of proteins to specific intracellular locations. More than 60 human Rab proteins have been identified, and their function has been shown to depend on their interaction with different Rab-associated proteins regulating Rab activation, post-translational modification and intracellular localization. The number of known inherited disorders of vesicle trafficking due to Rab cycle defects has increased substantially during the past decade. This review describes the important role played by Rab proteins in a number of rare monogenic diseases as well as common multifactorial human ones. Although the clinical phenotype in these monogenic inherited diseases is highly variable and dependent on the type of tissue in which the defective Rab or its associated protein is expressed, frequent features are hypopigmentation (Griscelli syndrome), eye defects (Choroideremia, Warburg Micro syndrome and Martsolf syndrome), disturbed immune function (Griscelli syndrome and Charcot–Marie–Tooth disease) and neurological dysfunction (X-linked non-specific mental retardation, Charcot–Marie–Tooth disease, Warburg Micro syndrome and Martsolf syndrome). There is also evidence that alterations in Rab function play an important role in the progression of multifactorial human diseases, such as infectious diseases and type 2 diabetes. Rab proteins must not only be bound to GTP, but they need also to be ‘prenylated’—i.e. bound to the cell membranes by isoprenes, which are intermediaries in the synthesis of cholesterol (e.g. geranyl geranyl or farnesyl compounds). This means that isoprenylation can be influenced by drugs such as statins, which inhibit isoprenylation, or biphosphonates, which inhibit that farnesyl pyrophosphate synthase necessary for Rab GTPase activity. Conclusion: Although protein-trafficking disorders are clinically heterogeneous and represented in almost every subspeciality of pediatrics, the identification of common pathogenic mechanisms may provide a better diagnosis and management of patients with still unknown Rab cycle defects and stimulate the development of therapeutic agents.     

Nasal continuous positive airway pressure for neonatal back transfer

We report the use of nasal continuous positive airway pressure (nCPAP) for neonatal back transfer of 51 babies. nCPAP may be used to provide safe respiratory support during back transportation of infants. Babies transferred on nCPAP were significantly smaller and of younger postmenstrual age than historical comparators who had to wait for transfer until independent of nCPAP. nCPAP transferred babies spent significantly less time on the intensive care unit.     

珠江三角洲新生儿转运网络工作报告

目的　评价珠江三角洲新生儿转运网络（ｎｅｏｎａｔａｌｔｒａｎｓｐｏｒｔｎｅｔｗｏｒｋ, ＮＴＮ） 十年工作及其效果。方法　介绍新生儿转运网络方法及分析有关效果的资料。结果　转运网络现有８７ 家医院;１０ 年共转运急危重症新生儿８ １２４ 例,转运途中死亡３５ 例,病死率为０．４３％ ;第三级新生儿监护病房（ＮＩＣＵ）收容８ ０８９ 例,共死亡３６４ 例,病死率为４．５０ ％ ,ＮＴＮ 医院中总死亡率为２．０７‰。结论　该ＮＴＮ 所实行的运转机制合理适用;促进了网络单位包括三级ＮＩＣＵ 的发展与提高;建立ＮＴＮ是降低新生儿死亡率的重要措施。     

Impact of service changes on neonatal transfer patterns over 10 years

INTRODUCTION: Many changes have been made to the staffing and organisation of neonatal care in the UK in the past 10 years. This study assessed the extent to which these changes had affected the transfer of babies between different parts of the service. METHODS: Data from the Trent Neonatal Survey, an ongoing study of neonatal intensive care activity in the former Trent Health Region of the UK, were used to evaluate neonatal inter-hospital transfers over a 10-year period, from 1 January 1995 to 31 December 2004. The number of transfers and the types of transfer were analysed and trends in gestation and disease severity over the study period were assessed. Rates of "inappropriate transfer" were also identified. RESULTS: 8105 babies were transferred over the period; 2294 babies underwent urgent postnatal transfer and this equates to approximately two such transfers every three days. The maximum number of journeys by any one baby was eight. Intensive care activity rose during the 10 years but the number of inappropriate transfers remained persistently high. CONCLUSIONS: Organisational changes in neonatal care during the 10-year period have been insufficient to deal with the rising demand, as reflected by the persistently high rate of inappropriate transfers.     

Control of temperature during newborn transport: An old problem with new difficulties

Objective: To explore any changes in temperature control during neonatal emergency inter-hospital transport between 1977 and 1996.
Methods: Records were reviewed of all infants undergoing emergency transfer by the statewide Victorian Newborn Emergency Transport Service (NETS). Per axillary temperatures were recorded prospectively on arrival of transport team and at conclusion of transfer for all infants.
Results: The rate of hypothermia (<36.0°C) when NETS reached the infant has decreased overall (22% in 1977–79 to 7% in 1995–96) and for all weight groups; although in 1995–96 hypothermia was present in 36% of infants less than 1000g when NETS arrived. The rate of hypothermia (<36.0°C) at the end of the transfer has remained at 3% overall for many years. The rate of hyperthermia at both times has increased significantly overall (12% in 1977–79 to 24% in 1995–96 on NETS arrival, 4%-19%, respectively at end of transfer) and for all weight groups except infants less than 1000g. The range of abnormal temperatures has not substantially changed over time.
Conclusion: There has been significant improvement in avoidance of hypothermia and cold stress amongst infants requiring emergency neonatal transport from 1977 to 1996. However, in order to improve the number of infants transferred who achieve a temperature in the normal range the need to avoid hyperthermia is highlighted. Infants who require incubator care for optimal medical management require continual monitoring of temperature and review of environmental conditions to optimise the conditions both prior to and during transport.     

Outcome of neonates transported between Level III centres depends upon centre of care

This study aimed to clarify whether the adverse outcomes seen in babies transported between New Zealand Level III intensive care nurseries were due to the transport itself or to possible differences in care in different centres. The outcomes of 34 infants inborn at National Women's Hospital, Auckland but transported to other centres were compared with those of 68 matched controls inborn at the receiving centres and with 68 controls inborn and cared for at National Women's Hospital. Transport was associated with a transient (non-significant) deterioration in respiratory status but no increase in chronic lung disease. However, infants cared for elsewhere, whether transported or control, had more periventricular haemorrhage than Auckland babies (23% and 29%vs 15%, P= 0.03) and worse neurodevelopmental outcome (70% and 66%vs 88% of those whose outcomes were known were normal at follow up, P= 0.002). We conclude that differences in care between centres may be more important than the transport itself in determining the long-term outcome of transported neonates.     

Nationwide survey of neonatal transportation practices in Japan

Rapid resuscitation and appropriate transportation of sick infants can greatly improve infant survival and neurological prognosis. To gain an understanding of the status of neonatal transport in Japan, we conducted a survey of neonatal transportation capabilities at perinatal medical centers across the country. Survey content included the number of neonatal transportation cases and the method of transportation. Twenty percent of infants admitted to neonatal intensive care units were transported to the medical centers from other institutions. Half of the level III perinatal medical centers owned an ambulance specialized for neonatal transport. A total of 36% of sick newborns, however, were transported by fire department ambulances that are ill‐equipped to care for infants. Thirteen percent of centers reported problems with the emergency transportation of newborns in fire department ambulances. Centers lacked specialized ambulances primarily because of financial constraints. Adequate medical insurance coverage is needed to increase the number of specialized ambulances at perinatal medical centers.     

Safety of synthetic surfactant use before preterm newborn transport

OBJECTIVE: The benefit of surfactant administration in preterm newborns is well described. The increase in lung compliance and other effects that it produces might however be dangerous in a transportation situation. This study examined the safety of surfactant (primarily Exosurf; Burroughs-Wellcome Research, Triangle Park, NC, USA) administration in preterm babies prior to their transportation from a peripheral hospital to a tertiary Neonatal Intensive Care Unit. METHODOLOGY: Two groups of babies were examined retrospectively over a 4-year period. One group, designated C (n = 46), received surfactant prior to transport and the other, designated Z (n = 85), did not. RESULTS: There was no significant difference in morbidity or mortality between the groups. The benefits of early surfactant were reinforced in Group C with fewer days ventilated while having no significant change in days on continuous positive airways pressure, in oxygen or days before discharge. During transport, mean airway pressure was unchanged but group C had a significantly greater drop in oxygen requirement. In those less than 30 weeks gestation, increased respiratory benefit was apparent in those who received pretransport surfactant. CONCLUSION: Administration of synthetic surfactant prior to preterm newborn transportation is safe with no intra-transport complications.     

2008年至2011年不良结局的转运新生儿病例分析

目的对近4年来转运人院的新生儿中发生不良结局者的特点进行分析，为提高本省围生儿的生存质量及降低病死率提供参考。方法回顾性分析2008年1月至2011年12月问转运病例中发生不良结局者255例患儿的临床资料，并按时间先后分为A组124例（2008年1月至2009年12月）及B组131例（2010年1月至2011年12月），分析其基本资料、围生期因素及主要疾病等情况，并比较患儿在不同时期相关特点的变化。结果发生不良结局者中男性患儿比例明显高于女性（男：女为3．05：1，192：63），早产儿比例高（73．3％，187／255），剖宫产比例高（49．0％，125／255）；主要疾病为呼吸系统疾病（71．4％，182／255），其次为循环系统疾病（40．4％，103／255）及严重先天发育异常（26．3％，67／255）。B组与A组比较：（1）住院时间〈24h者比例上升（73／131 vs 50／124，P〈0．05）；（2）经过2次以上转院者增加（41／131 vs 23／124，P〈0．05）；（3）极低出生体重儿（包括超低出生体重儿）显著增加（75／131 vs 43／124，P〈0．05）；（4）呼吸系统疾病（131／131 vs 124／124）及窒息（9／131 vs 22／124）、缺氧缺血性脑病（6／131 vs 16／124）显著下降（P〈0．05）；（5）循环系统疾病（60／131vs31／124）及先天发育异常者（51／131vs23／124）显著上升（P〈0．05）；（6）机械通气（115／131vs88／124）及肺表面活性物质应用（85／131vs52／124）显著增加（P〈0．05）；（7）血液制品使用率显著下降（39／131vs53／124，．P〈0．05）；（8）因经济等原因放弃治疗者显著减少（22／131vs37／124，P〈0．05）。结论基层医疗机构对转运时机及转诊医院的选择，可能影响不良结局的发生率；高剖宫产率可能增加不良结局的发生；极低及超低出生体重儿的救治能力可能直接影响不良结局的发生；呼吸系统疾病对不良结局影响大，但同时伴随的循环系统疾病对不良结局的影响近年增加。     

区域内危重新生儿转运体系的应用研究

目的：了解区域内危重新生儿转运现状及存在的问题,为建立区域内完善的新生儿转运体系提供参考。方法：选取2009年1月至2010年9月北京海淀区4所医院所有转诊新生儿为研究对象,并收集2所接诊医院的相关临床资料进行研究。结果：转诊疾病以早产儿、需外科急诊处理的疾病和呼吸系统疾病为前3位疾病（33.1%、18.3%、14.8%）。主动转诊95例（66.9%）,被动转诊47例（33.1%）。转诊时年龄＜6 h者占 24.1%,6 h~者占9.3%,12 h~者占25.9%,>24 h者占40.8%。从医院乘救护车至接诊病房时间为28.0±11.1 min。转诊后死因以需外科急诊治疗的疾病占第1位,占死亡病例的53.8%。转诊时年龄<6 h组和≥6 h 组的死亡率差异无统计学意义。结论：本研究区域内4所医院以主动转运为主。需手术治疗的外科疾病患儿转诊后死亡率高,应重视新生儿外科疾病患儿的转运工作。     

法洛四联症患儿心肌细胞内钙运转与心功能关系的研究

目的探讨法洛四联症(TOF)患儿心肌细胞钙运转与心功能的关系.方法钙荧光指示剂Fura-2法测定心肌细胞游离钙浓度,HP-1000型超声心动图机测定心功能.结果28例TOF患儿红细胞游离钙和总钙浓度较健康组明显高,而钙泵活性明显低下;其中8例舒张功能正常者红细胞钙泵活性与健康组无差别,而20例舒张功能异常者不仅钙泵和钠泵活性较舒张功能正常者明显下降,且红细胞游离钙和总钙浓度亦较舒张功能正常者升高.结论TOF患儿心肌细胞内钙运转与其心肌舒张功能异常密切相关.