Accuracy of clinical diagnosis and decision to commence intravenous prostaglandin E1 in neonates presenting with hypoxemia in a transport setting
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BACKGROUND: Setting goals for monitoring and initiating life-saving interventions such as prostaglandins (prostaglandin E(1) [PGE(1)]) during transport stabilization are dependent on establishing an accurate clinical diagnosis. OBJECTIVE: The aim of this study was to determine the accuracy of clinical diagnosis of suspected congenital heart disease (CHD) and the decision to initiate PGE(1) in neonates presenting with hypoxemia. METHODS: A retrospective cohort study (2002-2004) on hypoxemic neonates who were transported to an outborn neonatal intensive care unit (NICU) was conducted. Provisional diagnosis established by the transport team was categorized as suspected CHD (group 1), suspected persistent pulmonary hypertension of the newborn (group 2), and suspected CHD and/or persistent pulmonary hypertension of the newborn (group 3) based on history, physical examination, laboratory test, chest radiograph, and initial response to treatment. A definitive diagnosis was established on arrival to NICU by echocardiography. RESULTS: A total of 115 neonates were included in the study. The mean gestational age at birth, median age at admission to NICU, and the mean stabilization time were 38.2 (2.4) weeks, 1 (1-26) days, and 217 (108) hours, respectively. The interventions provided during transport stabilization included mechanical ventilation (n = 86, 75%), PGE(1) (n = 70, 61%), inotropes (n = 41, 36%), and fluid bolus (n = 50, 43%). The accuracy of a provisional diagnosis of CHD by transport team was 87.7% and the positive predictive value was 88.1%. Sixty neonates (88%) received PGE(1) appropriately. Eight neonates (12%) with duct-dependent CHD (n = 68) did not receive PGE(1) and were considered as missed opportunities. Ventilated neonates in groups 1 and 3 were identified as the groups that can potentially benefit from more liberal use of PGE(1) and without any adverse effects. CONCLUSION: Although the accuracy of a diagnosis of CHD and the decision to initiate PGE(1) was high, 12% of neonates with a duct-dependent CHD were transported without commencement of PGE(1). Lower thresholds for PGE(1) administration to hypoxemic neonates may potentially improve preoperative stabilization and minimize neonatal morbidity.
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