PLACE LABEL HERE
NEONATOLOGY SERVICE
TRANSPORT ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Diagnosis & Status: Admit as Inpatient _______________________________________________(reason for admission)
Current weight: _________________ grams
Gestational age: ________________ weeks
Date: ______________ Time: ___________
1. Obtain and record maternal and infant’s history including lab work previously drawn
2.
Obtain and record a complete physical assessment
3.
Call physician to report infant status and obtain orders
4. Place infant on cardiopulmonary monitor and pulse oximeter (set HR alarm at 100-200 bpm and apnea alarm at 20
seconds)
5.
Place peripheral IV or superficial UVC – notify physician if peripheral IV access takes longer than 10 min to obtain
6.
Make NPO and place appropriate NG/OG tube if indicated
7.
Obtain vital signs q 15 min and call physician with any significant change in clinical status
IV Fluids:
 D10W at 80 ml/kg/day for birth weight greater than 1.5 kg
 D10W at 100 ml/kg/day for birth weight 1 kg – 1.5 kg
 D10W at 110 ml/kg/day for birth weight 750 grams – 1 kg
 D10W at 120 ml/kg/day for birth weight less than 750 grams
 UAC fluid: NS 0.45 with heparin 1 unit/ml at 1 ml/hr, or run at 0.5 ml/hr if less than or equal to 1,000 grams
 UVC fluid: add heparin 1 unit/ml to ____________, run at ___ml/hr to maintain total intake at ______ml/kg/day
 PAL fluid: NS 0.45 plus 2% lidocaine 2ml /100ml plus sodium bicarbonate 0.25 mEq /100ml plus heparin 2 units/ml at 1
ml/hr, or run at 0.5 ml/hr if less than or equal to 1,000 grams
Medications:
 Give D10W 2ml/kg IV for blood glucose screen less than 40 mg/dL
 Repeat screen 30 min after bolus
 Repeat D10W bolus if follow up glucose screen less than 40 mg/dL
 Call physician if more than two consecutive D10W boluses are needed, or if glucose screen greater than 200
mg/dL on more than two consecutive screens
 NS 0.9% 15 ml/kg IV over 20 min
 Ampicillin 100 mg/kg IV times one dose
 Gentamicin 5 mg/kg IV q 48 hrs for infants less than 30 weeks
 Gentamicin 4.5 mg/kg IV q 36 hrs for infants 30 – 34 weeks (inclusive)
 Gentamicin 4 mg/kg IV q 24 hrs for all infants greater than 34 weeks
 _____________________________________________________________________
 Surfactant 2.5 ml/kg per ETT times one dose
 Fentanyl 2-4 micrograms/kg/dose IV q 2-4 hrs prn
 Norcuron 0.1 – 0.2 mg/kg q 1-2 hrs IV
 Phenobarbital 20 mg/kg IV times one dose
Order writer’s initials _______
Send copy to pharmacy
*3-17242*
FORM 3-17242 REV. 07/2012
Page 1 of 2
PLACE LABEL HERE
NEONATOLOGY SERVICE
TRANSPORT ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Laboratory:
 Blood gas (ABG, CBG, VBG)
 X-ray (CXR, KUB, Other_____________________)
 Blood glucose monitoring on arrival at referral hospital then q hr while on transport
Other:
 ______________________________________________________________________________________________
 ______________________________________________________________________________________________
 ______________________________________________________________________________________________
8.
Call physician with most recent vital signs, updated history, clinical condition of patient, available lab results and
ventilator settings before final departure from referring hospital
9.
Make telephone contact with physician for any significant changes in clinical status while in ambulance or if transport
time to GWP exceeds 1 hour
______________
Date
_____________
Time
______________________________________
Physician Signature
___________________
PID Number
Send copy to pharmacy
FORM 3-17242 REV. 07/2012
Page 2 of 2