Rapid Decompensation on Neonatal Transport: A Case Study (Do You Have the Answers?)

Let's Test That Critical Thinking

Neonatal transport presents unique challenges, especially when transferring critically ill infants with evolving conditions. One such condition can escalate rapidly, requiring quick decision-making and expert coordination between team members.

In this interactive case study, you'll step into the role of a neonatal transport nurse responding to a facility with a preterm infant in distress. With each step, you'll have the chance to assess symptoms, make critical stabilization decisions, and anticipate complications before and during transport. I recommend collapsing the individual sections so you aren't too tempted to read ahead. You'd hate to spoil the ending!

Are you ready? Let’s dive in.

Patient Presentation

You receive a call from a local Level III NICU about a 29-week gestation infant who was born via emergency C-section due to severe preeclampsia and absent end-diastolic flow on Doppler. Birth weight was 1,200g. APGARs were 5 and 7 at 1 and 5 minutes, respectively. The infant required CPAP support at delivery but was otherwise stable and admitted to the NICU for preterm management.

On day of life 12 the infant developed:

• Green emesis

• Abdominal distension and tenderness

• Hypoactive bowel sounds

• Episodes of apnea and bradycardia

  
  

1] Based on these symptoms, what are your initial concerns? What differential diagnoses would you consider?

2] What further diagnostics would you request to confirm your suspicions? What results would you anticipate given the diagnoses you're considering?

Labs, Imaging, and Vitals

Initial lab results showed:

• WBC: 2,500/mm³

• Platelets: 90,000/mm³

• CRP: 4.2 mg/dL

• Blood Gas: pH 7.25, HCO3 15

• Lactate: 5.6 mmol/L

• Blood Culture: Pending

Vital signs at onset of symptoms:

• HR: 168 bpm

• RR: 56 breaths per minute

• BP: 54/36 mmHg (MAP 42)

• Temperature: 36.5 °C

• SpO2: 95% on BCPAP PEEP 6 in 21% FiO2

A KUB showed pneumatosis intestinalis, confirming a diagnosis of NEC.

Due to worsening clinical status, the decision was made to transfer the infant to a higher-level NICU with surgical capabilities.

3] Given these lab results, what do we know about the infant? What can we anticipate about the care they will need?

4] Prior to the team's arrival at the referring hospital, what stabilization steps would you recommend they perform for this infant?

Pre-Transport Recommendations

Pre-transport stabilization recommendations:

• Initiate NPO status, if not already

• Obtain IV access and start D10 to maintain hydration

• Place a gastric decompression tube to decompress the stomach

• Start broad-spectrum antibiotics (ampicillin, gentamicin/amikacin)

• Monitor need for increased respiratory support

  
  

Updated vital signs en route:

• HR: 172 bpm

• RR: 60 breaths per minute

• BP: 48/30 mmHg (MAP 36)

• Temperature: 36.2 °C

• SpO2: 91% on BCPAP PEEP 6 in 21% FiO2

  
  

5] How do the pre-transport vital signs compare to earlier? What concerns are starting to arise?

Transport Team Arrival

Upon arrival, the transport team performs a full physical assessment and notes the following:

• General appearance: Lethargic, pale, with decreased spontaneous movement

• Skin: Mottling noted on trunk and extremities, capillary refill > 4 seconds

• Abdomen: Firm, distended, with visible loops of bowel; hypoactive bowel sounds. Gastric decompression tube in place to low intermittent wall suction and functioning properly

• Respiratory: Increased work of breathing, retractions. The bedside nurse reports increasing apnea spells

• Cardiovascular: Tachycardic with weak peripheral pulses

• Neurological: Minimal response to stimuli

• D10 is running via a PIV in the right forearm at TF of 120

  
  

Vital signs on arrival:

• HR: 175 bpm

• RR: 68 breaths per minute

• BP: 38/18 mmHg (MAP 24)

• Temperature: 36.3 °C

• SpO2: 96% on BCPAP PEEP 6 in 40% FiO2

The team determines that the referring facility successfully completed the pre-transport stabilization recommendations, including starting broad-spectrum antibiotics.

6] The physical assessment findings and updated vital signs are obviously concerning. How do they influence your transport plan? What procedures might you consider prior to leaving the facility?

Stabilization

Given the infant's poor appearance and escalating respiratory support, the team opts to intubate. You are successful after one attempt and secure an uncuffed 3.0 ETT at 7 cm at the gum. Shortly after intubation a decrease in work of breathing is noted and the FiO2 is able to be weaned to 25%. Dopamine is also started at 2 mcg/kg/min due to hypotension. The infant is placed on a warming mattress and bundled before being placed in the transport incubator. Prior to leaving the hospital you call back to medical control to communicate updates with the receiving NICU team and to recommend immediate surgical consult be available upon your arrival.

7] What consideration might have prompted the decision for the immediate surgical consult request?

8] Prior to leaving the hospital, you sit down with the parents of the infant to get their consent and answer their questions. They want to know what the plan will be. What are you prepared to tell them?

Arrival and Outcome

Upon arrival, the infant is diagnosed with Stage III NEC with bowel perforation. Emergent laparotomy at the bedside reveals extensive necrotic bowel, requiring a bowel resection with ostomy placement.

Key Neonatal Transport Case Study Takeaways

1. Early recognition of NEC symptoms can significantly impact outcomes.

2. Pre-transport stabilization is crucial— maintaining perfusion and minimizing gut distension can prevent rapid deterioration.

3. Close communication with the receiving team allows for immediate intervention upon arrival.

4. Anticipating potential complications (like shock or bowel perforation) helps guide transport interventions.

5. Family communication and emotional support should be a priority— helping parents understand the severity while remaining supportive.

NEC remains one of the most devastating conditions in preterm infants, with high morbidity and mortality. As transport providers, our role in early recognition, stabilization, and seamless handoff to higher-level care is critical.

Read more case studies and neonatal transport tips on the blog!