Severe Neonatal Respiratory Failure and Transfer for Higher Level Intensive Care: Early Factors Associated With Mortality and Other Outcomes in a Retrospective Cohort, 2018-2020.

Abstract

Objectives: To identify factors associated with death, requirement for extracorporeal membrane oxygenation (ECMO), or cardiac intervention in neonates referred for higher level neonatal ICU (NICU) due to respiratory failure.

Design: Retrospective cohort study, 2018-2020.

Setting: Referrals for transport to tertiary-level NICUs using the London Neonatal Transfer Service in the United Kingdom.

Patients: Neonates with a diagnosis of severe respiratory failure who were intubated and receiving Fio2 greater than 60% at referral. We excluded neonates younger than 34 weeks corrected gestational age, less than 2 kg, or with a known cardiac diagnosis.

Interventions: None.

Measurements and main results: We identified 170 neonates with a median (interquartile range [IQR]) age of 4 hours (2-11 hr) at referral and 9 hours (IQR, 7-16 hr) at time of departure from the referring NICU. Overall, 21 of 170 babies required immediate transfer to a center providing ECMO, of whom two of 21 died and two of 21 received ECMO support. Of the 149 transferred to NICUs that do not provide ECMO, 11 of 149 died (7%) and a further 16 of 149 (11%) required secondary transfers to an ECMO center where one of 16 died and three of 16 required ECMO. In total, there were 23 of 170 neonates with outcome of death, need for ECMO, or cardiac intervention. A composite score of Vasoactive-Inotropic Score (VIS) greater than or equal to 18 and oxygenation index (OI) greater than 24 after patient stabilization was associated with death, a need for ECMO or a previously undiagnosed cardiac lesion, with a sensitivity of 83% and a specificity of 73%.

Conclusions: This 2018-2020 cohort of neonates with severe respiratory failure managed in London, United Kingdom, shows that VIS greater than or equal to 18 and OI greater than 24 after stabilization were associated with death, need for ECMO, or cardiac intervention. These parameters may have the potential to trigger discussion with ECMO centers for early consideration of transfer but needs validation in a wider neonatal population.