Papers by Nandiran Ratnavel
Archives of Disease in Childhood, 2015
F1000Research, 2020
The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as t... more The best way to ensure that preterm infants benefit from relevant neonatal expertise as soon as they are born is to transfer the mother and baby to an appropriately specialised neonatal facility before birth (“in utero”). This review explores the evidence surrounding the importance of being born in the right unit, the advantages of in utero transfers compared to ex utero transfers, and how to accurately assess which women are at most risk of delivering early and the challenges of in utero transfers. Accurate identification of the women most at risk of preterm birth is key to prioritising who to transfer antenatally, but the administrative burden and pathway variation of in utero transfer in the UK are likely to compromise optimal clinical care. Women reported the impact that in utero transfers have on them, including the emotional and financial burdens of being transferred and the anxiety surrounding domestic and logistical concerns related to being away from home. The final section...
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2020
Hypoxic ischaemic encephalopathy (HIE) is a major cause of neonatal mortality worldwide. It can l... more Hypoxic ischaemic encephalopathy (HIE) is a major cause of neonatal mortality worldwide. It can lead to severe adverse neurodevelopmental outcomes among survivors. Therapeutic hypothermia is neuroprotective and is a standard of care.1 Active cooling via servo control is superior to passive cooling in achieving target temperature during neonatal transport in infants with HIE.2 These transfers are considered time critical transfers in London, in order to achieve a target temperature of 33–34°C within 6 hours of birth. Some local neonatal units within London have access to cooling machines and are therefore able to attain target temperature prior to transport team arrival. It was noted that where infants had already …
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2019
Extremely preterm and extremely low birth weight (ELBW) infants are prone to severe hypothermia a... more Extremely preterm and extremely low birth weight (ELBW) infants are prone to severe hypothermia and standard practices may not be adequate for thermoregulation during interhospital transfer.1 Transwarmer mattresses carry a risk of serious burns,2 and a safety warning has also been recently issued by British Association of Perinatal Medicine (BAPM) about their use. The servo-controlled device with mattress (SCDM) is conventionally used for cooling in term infants with hypoxic-ischaemic encephalopathy.3 There is no literature on its use for thermoregulation in ELBW infants. The theoretical risks associated with use of the SCDM and rectal probes include rectal perforation, rectal bleeding, skin damage from probe dressings and burns from the mattress.4 The aim of our quality improvement (QI) project was to look at the feasibility and effectiveness of the SCDM for thermoregulation during transport of infants born at ≤28 weeks …
Journal of Paediatrics and Child Health, 2019
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2017
Newborn infants with bilious vomiting: a national audit of neonatal transport services. Archives ... more Newborn infants with bilious vomiting: a national audit of neonatal transport services. Archives of Disease in Childhood, 102 (6). F515-518.
American Journal of Perinatology, 2016
Objective The recent availability of servo-controlled cooling equipment on transport makes it pos... more Objective The recent availability of servo-controlled cooling equipment on transport makes it possible to commence active cooling at the referral unit for infants with hypoxic-ischemic encephalopathy. This study aimed to compare the temperature and transfer variables in passively and actively cooled babies. Study Design This is a retrospective cohort study comparing two groups-passively cooled (July 2011 to August 2012) versus actively cooled group (September 2012 to June 2013), following introduction of active hypothermia using servo-controlled cooling mattress by the London Neonatal Transfer Service (NTS). Results Seventy-six infants were passively cooled and 69 were actively cooled. There was a significant difference between the temperatures of the two groups at each point in the transfer episode: on arrival of NTS, during stabilization, during transfer, and at the receiving hospital. Median time to achieve target temperature was 30 (95% confidence interval [CI]: 23-37) minutes in actively cooled, significantly shorter in comparison to 130 (95% CI: 83-177) minutes in passively cooled babies. Of the 69 newborns, 62 (90%) had temperature within target range at receiving center in actively cooled group as compared with 30/76 (40%) in passively cooled group. Conclusion The use of active cooling during neonatal transfer achieves target temperature in a shorter period and maintains better temperature stability.
Archives of Disease in Childhood - Fetal and Neonatal Edition
The Journal of Maternal-Fetal Medicine
Presented in the 24th European Congress of Perinatal Medicine (ECPM), Florence, Italy
The Journal of Maternal-Fetal Medicine
Presented in the 24th European Congress of Perinatal Medicine (ECPM), Florence, Italy
Rennie & Roberton's Textbook of Neonatology, 2012
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2014
ABSTRACT To evaluate the usefulness of a network based multi-professional neonatal emergencies te... more ABSTRACT To evaluate the usefulness of a network based multi-professional neonatal emergencies team training simulation course on participant's self-perceived level of confidence in dealing with neonatal emergencies.
Archives of Disease in Childhood, 2012
Purpose To indicate the prevalence of elevated serum aminotransferases at the time of child's adm... more Purpose To indicate the prevalence of elevated serum aminotransferases at the time of child's admission, the epidemiologic aspects of these abnormal values. Materials and Methods We performed an observational, retrospective study (January-December 2008) in which we studied demographic data (age, sex distrbution), biological findings, correlation between age and level of enzymes or etiology. The analysis was performed usig Microsoft Excel 2007 and SPSS Statistics 17.0. Results We studied 925 children aged 1month-18 years (8% of 11797 admission in a pediatric hospital) with abnormal serum aminotransferases. The highest frequency was noticed in male (54.4%, p<0,008). In the majority of cases hepatocytolysis was minor. Corelating the aminotransferases values with age we discovered that lower values are more prevalent with smaller ages, while higher values were encountered in children above 14 years. As etiology the majority of cases is represented by cytolysis with no obvious cause (87%) and, out of this population, by non-specific infectious diseases. Conclusions Elevated serum aminotransferases are frequently encountered in hospitalized children. The lower values prevail in the context of non-specific infectious diseases. Small children are more susceptible to hepato-muscular injury by non-specific infectious diseases. Therefore we highlight the necessity for further prospective studies in order to investigate if incidentally discovered abnormal serum aminotransferaseses children.
BMJ, 2014
Intestinal malrotation and volvulus in infants can be easily missed. The authors highlight the su... more Intestinal malrotation and volvulus in infants can be easily missed. The authors highlight the substantial risk of mortality and morbidity and recommend immediate surgical referral.1 In our experience as a regional neonatal transfer service for London, despite recognition of risks in infants with bilious vomiting, they are not prioritised for transfer to surgical centres. We recently audited 163 term infants with bilious vomiting transferred at ≤7 days of …
Archives of Disease in Childhood, 2014
Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer... more Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer requests to surgical centres. The aim of this study was to assess the use of clinical findings at referral in predicting outcomes and to determine how often such patients have a time-critical surgical condition (eg, volvulus, where a delay in treatment is likely to compromise gut viability).Methods4-year data and outcomes of all term newborns aged ≤7 days with bilious vomiting transferred by a regional transfer service were analysed. Specificity, sensitivity, likelihood ratios, correlations, prior and posterior probability of clinical findings in predicting newborns with surgical diagnosis were calculated.ResultsOf 163 neonates with bilious vomiting, 75 (46%) had a surgical diagnosis and 23 (14.1%) had a time-critical surgical condition. The diagnosis of a surgical condition in neonates with bilious vomiting was significantly associated with abdominal distension (χ2=5.17, p=0.023), abdo...
Pediatric Research, 2011
Background: Non-invasive carbon dioxide (CO 2) monitoring in mechanically-ventilated preterm babi... more Background: Non-invasive carbon dioxide (CO 2) monitoring in mechanically-ventilated preterm babies in the first few days of life is essential during neonatal stabilisation/transport. This helps to keep CO 2 levels in an acceptable range avoiding the risks associated with hypo-and hypercarbia, and minimises repeated arterial sampling and its associated complications. End-tidal CO 2 (EtCO 2) monitoring is of value in identifying certain ventilation problems, and proven to be effective in children and adults. The reports of its use in neonates are controversial. Objective: To assess the accuracy of measurements of EtCO 2 during neonatal transport of mechanicallyventilated preterm infants as compared with the partial pressure of arterial CO 2 (PaCO 2) measurements collected simultaneously. Design: Retrospective study on 221 paired EtCO 2 /PaCO 2 recordings taken during stabilisation/road transport of 125 mechanically-ventilated PT infants. The paired CO 2 values were compared and the differences between both were analysed. The Bland-Altman method was used to assess bias and repeatability. Results: EtCO 2 correlated significantly with PaCO 2. However, the correlation was extremely poor (r=0.39, p< 0.0001, 95% limits of agreement: 0.1996-0.4428). EtCO 2 underestimated PaCO 2 at a significant level (mean [SD] 2.595 [1.418] kPa), and did not trend reliably over time within individual subjects (r=0.15, p=0.12). The EtCO 2 bias was independent of the PaCO 2 level range and lung disease severity in terms of gas exchange or shunting. After correction of EtCO 2 with the mean bias, 58% of EtCO 2 values fell within 1 kPa of PaCO 2 values. Conclusions: EtCO 2 has an unacceptable under-recording bias when compared to the simultaneous PaCO 2 value.
Pediatric Research, 2011
Background and aims: There is increasing evidence that therapeutic hypothermia may improve surviv... more Background and aims: There is increasing evidence that therapeutic hypothermia may improve survival and reduce the rate of disability in infants with neonatal encephalopathy. The aim of this study was to evaluate the referrals for cooling received by London Neonatal Transfer Service (NTS) and assess their adherence to the enrolment criteria used by the TOBY study (Azzopardi et al NEJM 2009).
Pediatric Research, 2011
How could we use the meeting at Stanford as an opportunity to develop a WAC general code of ethic... more How could we use the meeting at Stanford as an opportunity to develop a WAC general code of ethics and yet break away from proscriptive statements that tend to be hierarchical and linear, especially considering those attending the meeting did not all necessarily agree on what such a code should be trying to achieve or have any clear idea of what form/s it might take. Moreover, fundamental differences existed in our understandings of basic concepts, such as social justice and the roles of archaeology in society, which underlie any approach we might take. These tensions led to an agreement that our work should focus on developing a conceptual process, supported by documents and tools for thinking about ethics. While Sean feels this is on the right track, he raises practical concerns that WAC might need to take a more proactive stance, providing mechanisms, processes and resources for the mediation and resolution of ethical disputes that will meet the needs of disenfranchised peoples who may turn to WAC seeking redress for injustices.
Pediatric Critical Care Medicine, 2008
To categorize and quantify adverse events occurring during emergency interhospital transfers perf... more To categorize and quantify adverse events occurring during emergency interhospital transfers performed by a specialized neonatal retrieval team and to assign levels of associated risk. Prospective review of adverse events during emergency interhospital transfers of neonates by the London Neonatal Transfer Service over a 6-month period. The events were categorized based on an adapted retrieval team model from the Paediatric &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Neonatal Safe Transfer and Retrieval Course (PANSTAR). Risk levels were measured using a modified risk assessment score. Emergency interhospital transfers by a specialized neonatal retrieval team. Patients were 346 emergency neonatal transfers over 6 months. None. We found that 125 transfers (36.1%) had at least one adverse event. There were 205 adverse events in total; 139 events (67%) were perceived as being due to avoidable human errors. Almost a third of events (30%) occurred even before the retrieval team arrived at the referring hospital and made contact with the patient. The largest group of events occurred due to problems in preparation (n = 69) and communication (n = 49). Most events (n = 143) had insignificant impacts on patients, but six events could have potentially caused major harm. Adverse events commonly occur during neonatal transfers, even if performed by a dedicated transfer service. Early identification of potentially harmful episodes is important. Human error is likely to be a factor in the majority of adverse events; hence, opportunities should be taken to reduce the number of these through education, training, and risk management.
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Papers by Nandiran Ratnavel