Garth D . Meckler and Calvin Lowe 1 To Intubate or Not to Intubate ? Transporting Infants on Prostaglandin

OBJECTIVES. The purpose of this work was to describe the pretransport and transport management of infants receiving prostaglandin E1 infusion for congenital heart disease and to compare transport complications among unintubated and electively intubated infants. METHODS.We conducted a retrospective chart review of 202 infants receiving prostaglandin E1 during transport to our facility from 2000 to 2005. Prostaglandin E1 adverse effects were described as likely or possible and transport complications as major or minor (requiring no intervention). Logistic regression was used to identify risk factors for major transport complications, and subgroup analysis compared risks among unintubated and prophylactically intubated infants. RESULTS. Sixty-four percent of infants were intubated before transport: 34% emergently before prostaglandin E1, 14% for prostaglandin E1-related adverse effects, and 11% prophylactically. Likely prostaglandin E1 adverse effects were noted in 38% of infants, including 18% with apnea. Major complications occurred during 42% of all of the transports, including 7 (10%) of 73 unintubated infants and 14 (61%) of 23 prophylactically intubated infants. After controlling for multiple factors, elective intubation was a significant predictor of major transport complications. CONCLUSIONS.Despite high rates of prostaglandin E1 adverse effects, elective intubation of infants for transport significantly increased the odds of a major transport complication. The risks of prophylactic intubation before the transport of otherwise stable infants on prostaglandin E1 must be weighed carefully against possible benefits. Pediatrics 2009;123:e25–e30 I 1981 THE Food and Drug Administration approved prostaglandin E1 (PGE1) for use in neonates with congenital heart defects (CHDs). PGE1 dilates the ductus arteriosus, which can provide pulmonary or systemic blood flow to infants with ductal-dependent lesions.1–6 As new surgical techniques improve the prognosis for a range of CHD, the early use of PGE1 has become widespread before transport to regional medical centers for definitive care. PGE1 infusion, however, has been associated with serious adverse effects, including apnea, hypotension, and fever.7,8 Concern for apnea and the technical difficulties securing a definitive airway during transport has lead to the common practice of elective intubation for infants receiving PGE1 before transport.9,10 Endotracheal intubation, however, carries its own risks and may add to the potential for adverse events during transport, such as endotracheal tube occlusion, displacement, and equipment failure.10–15 Few studies have examined the complications associated with interhospital transport of infants receiving PGE1, and no standard of care for the preparation of these infants currently exists. We hypothesized that stable infants could safely be transported without endotracheal intubation. Therefore, we sought to describe the pretransport management of infants receiving PGE1 infusions and to compare the transport complications of unintubated and electively intubated infants. PATIENTS ANDMETHODS We conducted a retrospective review of the medical charts of infants transported to Children’s Hospital of Los Angeles with a diagnosis of CHD from January of 2000 to December of 2005. Subjects were included if they were transported www.pediatrics.org/cgi/doi/10.1542/ peds.2008-0641 doi:10.1542/peds.2008-0641