What are the benefits of transferring a newborn or premature infant from the Neonatal Intensive Care Unit (NICU) to the Operating Room (OR) for surgical intervention?

Benefits of Transferring NICU Patients to the Operating Room

For neonates requiring surgical intervention, performing the operation in the NICU rather than transferring to the OR is the preferred approach when feasible, as it prevents hypothermia, maintains continuity of critical care, and avoids life-threatening complications like accidental extubation or vascular access loss. 1

Primary Benefits of NICU-Based Surgery

When surgical procedures can be performed in the NICU setting:

• Prevention of hypothermia during transport and procedure, which is critical since hypothermia increases mortality and morbidity including respiratory distress syndrome, metabolic derangements, intraventricular hemorrhage, and late-onset sepsis 2, 1

• Uninterrupted critical care with continuous mechanical ventilation, hemodynamic monitoring, and vasoactive medication infusions without the dangerous interruptions that occur during transport 1

• Elimination of transport-related complications including accidental extubation, vascular access dislodgement, and hemodynamic instability that frequently occur during intrahospital transfers 3, 1

• Ability to optimize ventilation strategies such as switching from conventional to high-frequency ventilation for severe respiratory failure without transport delays 1

When OR Transfer is Necessary

For complex surgical procedures requiring specialized equipment or cardiopulmonary bypass that cannot be performed at bedside, transfer to the OR becomes necessary despite the risks 3:

• Level IV NICU capabilities include access to ORs with pediatric surgical specialists available 24/7 for repair of complex congenital cardiac malformations and other conditions requiring advanced surgical intervention 3

• Time-critical surgical conditions in extremely preterm infants (extradural hematoma, acute subdural hematoma with mass effect, obstructive hydrocephalus) require immediate OR access at tertiary centers 3

Critical Safety Measures for OR Transfers

When NICU-to-OR transfer is unavoidable, strict protocols must be followed:

• Pre-transfer stabilization to achieve physiological homeostasis before moving the patient, as patient factors rarely cause adverse events when proper stabilization occurs 3

• Standardized handoff tools with face-to-face communication between NICU and OR teams, defining which team members must be present, and including family communication to reduce medical errors 4

• Competent transport teams including physicians experienced in airway management, with properly tested ventilator settings (FiO2, PEEP, respiratory rate, tidal volume, airway pressure alarms) and sufficient oxygen reserves with 30-minute backup supply 3

• Equipment preparation ensuring age-appropriate transport ventilators, monitoring devices, and multi-point harness restraints for securing infants to stretchers 3

Outcomes Impact

The delivery setting and transfer decisions have measurable effects on neonatal outcomes:

• Antenatal transfer superior to postnatal transport: Periviable infants requiring intervention should be delivered at Level III-IV centers, as antenatal maternal transfer significantly improves neonatal outcomes compared to transferring the baby after birth 5, 2

• Reduced time to definitive care: Specialized transfer systems for critically ill surgical patients decrease time from referral to OR (118 vs 223 minutes) and reduce hospital length of stay (13 vs 17 days) 6

• Active management benefits: Extremely preterm infants admitted to NICUs without active antenatal management (no antenatal steroids, magnesium sulfate, or cesarean for fetal indications) have significantly higher risk of death or severe morbidity (adjusted OR 1.86,95% CI 1.09-3.20) 7

Common Pitfalls to Avoid

• Do not transport unstable patients: Ensure complete stabilization before any intrahospital transfer, as 83% of adverse events during transport result from human error, particularly inadequate pre-transport preparation 3

• Do not underestimate oxygen requirements: Calculate total oxygen needs for the entire transport duration plus 30-minute reserve to prevent catastrophic desaturation 3

• Do not perform unnecessary transfers: Approximately 19% of surgical transfers result in no intervention and discharge within 72 hours; use remote consultation and interfacility collaboration to avoid subjecting fragile neonates to avoidable transport risks 8

• Do not allow temperature drops: Maintain delivery room temperature at minimum 23°C, use thermal mattresses, plastic wraps, caps, and warmed humidified gases for preterm infants during any transport 2