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Transport of the critically ill child
SYMPOSIUM: INTENSIVE CARE
Transport of the critically ill child
or more commonly because the child’s condition is deemed to be time-critical. The commonest reasons for a time-critical transfer include an expanding intracranial mass lesion (e.g. extradural haematoma), a blocked ventriculo-peritoneal shunt or a general surgical emergency (e.g. small bowel volvulus). The above figures relate to inter-hospital transfers, however there are many more intra-hospital transfers of critically ill patients as well as inter-hospital transfer of non-critically ill children which are more often than not done by non-PIC specialist teams, though they carry many of the same risks. While transfer can be done on land air or sea, land transfer using an ambulance is by far the most common, and is the one we will focus on here.
Avishay Sarfatti Padmanabhan Ramnarayan
Abstract With the centralization of specialist services into a limited number of hospitals across the UK, an increasing number of children require an inter-hospital transfer. In 2014, 6000 critically ill or injured children were transferred between hospitals in the UK. While most of the transfers are done by specialist teams, as many as 23% are done by nonspecialist teams. These patients are some of the sickest children. It is while in transit that these patients are most at risk, and the transferring team is most exposed. To achieve a smooth and safe transfer it is important that the appropriate team with the relevant skills undertakes such transfers. The patient’s condition should be optimised before transfer and any likely difficulties are anticipated, and that the transferring team is prepared to act to resolve any complications swiftly and effectively. In this review we will attempt to offer our approach to the safe transfer of the critically ill child.
Stabilisation and preparation for transfer Unwell children should be stabilized prior to transfer. Most PIC transfer services in the UK have clinical management guidelines for the common presentations available on-line (see Further reading). Any interventions that are likely to improve outcome should also be done prior to transfer. There are, however, occasions, when definitive treatment can only be given at a specialist centre, and delaying transfer is likely to be deleterious. An example is the child with an expanding intracranial haematoma who requires a neurosurgical intervention. In such instances, any intervention considered should be weighed against the harm that may come from delaying transfer. When stabilizing and preparing a child for transfer, a system based approach is helpful. There should be clear leadership, with the key goals clear to all team members. Different aspects of the management should be delegated within the team so that the work can be done in parallel, minimising delays. Throughout the process of stabilization and preparation for transfer, communication with the regional PICU/PIC transfer service should be maintained, so that the PIC clinician can offer advice on clinical management, and make the necessary preparations to receive the child at the regional centre. Some examples of our advice offered in some of the commoner clinical situations are given in Figure 1.
Keywords critical illness; critical injury; inter-hospital transport; paediatric intensive care; stabilization
Introduction The reorganization of Paediatric Intensive Care services in the UK into regional centres has increased the need to transfer children between hospitals. The Paediatric Intensive Care Audit Network (PICANet), an international audit network that collects information on all children admitted to Paediatric Intensive Care in the UK and the Republic of Ireland, found in its 2015 annual report that “just over half of all emergency admissions to paediatric intensive care units (PICUs) in the United Kingdom are for sick children who first present at their local hospital and require stabilisation and transport to a hospital with a PICU. Over 6000 very sick children were transported to PICU in 2014.” The report further found that 77% of paediatric critical care transfers were done by specialist Paediatric Intensive Care (PIC) teams, with the remaining 23% being done by a variety of other teams with varying skill sets. These children are some of the sickest paediatric patients with a crude mortality of 8%. The outcome of the critically ill or injured child is better when the transfer is carried out by a PIC specialist team. Transfer is done by local teams either because such a team is not available,
The first conversation Once the need to transfer a critically ill or injured child is established, the regional PIC retrieval service should be contacted, and the management of the child should be discussed. To provide useful advice the PIC consultant will require some basic patient demographics (including working weight), a working diagnosis, a brief history, therapeutic interventions already instituted and their effect, and the current clinical status. The person allocated to the task ought to be familiar with the case, have recent observations, results of relevant investigations, and a recent blood gas analysis at hand. It is preferable that conversations be undertaken between the most senior staff member available locally and the most senior PIC staff member available. The discussion should achieve the following: Provide the front line team with relevant clinical advice for ongoing management. Reach a joint decision about the need for secondary transfer, and the destination. Establish who should undertake the transfer and the time scale for departure.
Avishay Sarfatti MRCPCH BMBCH MA, Specialist Trainee in Paediatric Intensive Care Medicine, Children’s Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Conflict of interest: none declared. Padmanabhan Ramnarayan FRCPCH FFICM MD, Consultant Paediatric Intensive Care Medicine, Children’s Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Conflict of interest: none declared.
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SYMPOSIUM: INTENSIVE CARE
Asthma
Sepsis
•Use PEEP of 4-6 cmH2 0 •PIP < 35 cmH20 •Avoid breath stacking by using a slow respiratory rate to allow a prolong expiratory time •Permissive hypercapnia as long as pH is >7.2 •Physiotherapy and endotracheal suctioning •Manual chest decompression by experienced personnel if breath stacking is a problem •Avoid Morphine / Atracurium infusions due to associated histamine release •Intubate early (once 40ml/kg of fluid given) as risk of pulmonary oedema is high • High risk of cardiovascular instability at the time of intubation • Use Ketamine and Fentanyl for induction •Have fluid boluses and inotropes ready •Use appropriately sized cuffed ETT. In severe sepsis, high PEEP / HFOV may be needed to overcome pulmonary oedema •Do not delay inotropes due to difficult IV access. Obtain early IO access
Brain injury
•Avoid hypoxia / hypotension •Tight control of PaCO2 within normal range •Ensure well sedated and paralysed to avoid rise in ICP •Use boluses of Fentanyl 2-5mcg/kg for any procedures such as suctioning • Target a high normal BP •Use hypertonic saline 3ml/kg of 2.7% Saline to manage episodes of intracranial hypertension •Avoid hypoglycaemia / hyperthermia •Transfer to a neurosurgical centre without delay
BronchioliƟs
•Try High flow humidified oxygen or CPAP •Intubate for worsening respiratory failure or apnoeas •But remember that apnoeas could be a sign of CNS pathology i.e. meningitis, intracranial haemorrhage •Suction and physiotherapy
Pulmonary Hypertension
•Sedate and paralyse •Aim Sats >95% •Aim normal pH 7.45 and PaCO2 4-5 kPa •Aim for high - normal BP •Consider need for inhaled Nitric Oxide (iNO)
Figure 1 Management considerations of common paediatric emergencies.
Determine which intervention should be done prior to transfer, and which ones should be postponed so as not to delay the transfer. In the event that the local team will be undertaking the transfer, likely complications and their management should be discussed. The conversation should be done in such a way as to allow the parallel ongoing clinical management of the child, and should not take key personnel away from the bedside.
available and working and that key steps are not missed. The checklist should include: The choice of induction agent and neuromuscular blocking agents. This should be guided by the clinical scenario. We find that Ketamine (2 mg/kg IV) Fentanyl (2e5 mcg/kg IV) for induction, followed by Rocuronium (1 mg/kg IV) is suitable on most occasions. They provide optimal intubating conditions rapidly, have an acceptable side effects profile, and are relatively cardiovascularly stable. Previous concerns that Ketamine causes a spike in intracranial pressure have been refuted. Preparation for potential haemodynamic instability. Fluid boluses and inotropes are to be drawn up and ready for use for all intubations. A naso/oro-gastric tube. This is a very useful adjunct to tracheal intubation in young children. A stomach distended with air will impede ventilation significantly in this group of patients. A plan for the management of a difficult airway should be clear to all. It should be in line with Difficult Airway Society guidelines. Identification and location of the appropriate sized laryngeal mask airway (LMA) before attempted intubation. Doing so as an emergency when dealing with a difficult intubation will add unnecessary stress. While some controversy still exists regarding the use of cuffed endotracheal tube (ETT), it is our practice to use cuffed ETT on
The team The transferring team should include a medical doctor or a specialist nurse practitioner with advanced airway skills and experience in paediatric intensive care and critical transfer, and an intensive care nurse who is experienced in inter-hospital transfers. Both should be familiar with the transfer equipment. A driver familiar with the transfer ambulance is a part of the team.
Airway The child must have a safe airway for the duration of the transfer. A low threshold for elective tracheal intubation before transfer should guide management. Intubation during transfer carries a significant risk and should be avoided if possible. A paediatric intubation checklist should be used. This will bring the team together, ensure that all necessary equipment is
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most occasions, so long as the ETT internal diameter is greater than 3.0 mm. Children are PEEP-dependent and therefore do not tolerate a leak around the ETT. If necessary the cuff can be deflated. After successful intubation the ETT should be secured in a safe way. Adult ETT ties are insufficient. Children have a shorter trachea than adults and small movements can result in endobronchial intubation, or worse, a dislodged ETT. It is our practice to use a modification of the Melbourne strapping to secure all ETTs on transfer (see Figure 2). End-tidal carbon dioxide (EtCO2) monitoring will ensure the early recognition of any displaced ETT and for that reason its use should be mandatory in the transfer of intubated children. If the intubation was not done by the transferring team, the details of the intubation including drugs used, grade of airway on laryngoscopy and any difficulties encountered should be familiar to the transferring team. A post-intubation chest radiograph (CXR) should always be done and the position of the ETT noted. The optimal ETT position is when the tip is at the level of T2 (providing the child’s head is in the neutral position when chest radiograph is taken). While the recommendations for cervical (C-)spine immobilisation have changed over the last few years any sedated and paralysed trauma patients should have their C-spine immobilised during transfer. Lastly, a patient specific airway bag should be prepared (Table 1) and readily available throughout the journey.
The airway bag The Airway Bag e all equipment should be age and weight appropriate A selection of ETT e the same size as used as well as one size up and one size down Suction catheters e a Yankauer suction catheter and several ETT suction catheters Appropriate size laryngoscope blade and two handles An oropharyngeal airway (Guedel) A laryngeal mask airway (LMA) A face mask Bagging circuit A self-inflating bagging circuit Tapes to secure an ETT Magill forceps Table 1
the EtCO2 and arterial PaCO2 should be noted. Any further changes on transfer will be guided by oxygen saturation and EtCO2 monitoring. All ventilated children should have a gastric tube sited and on free drainage as decompressing the stomach aids ventilation and prevents regurgitation. Most children with lung pathology will benefit from physiotherapy, aimed to remove secretions from the airway and recruiting atelectatic segments of lung. Whenever possible a paediatric physiotherapist should be asked to aid in this. If not available, this may need to be done by the medical team at the bedside. Guidance on how to do this will be given by the regional PIC team. One should recognise that there are occasions when ventilation can only be optimised so much at the local hospital. These occasions are rare, and should be discussed with the regional PIC consultant, who may advise to transfer the child without further delay to an appropriate PICU for the level of organ support that the child is likely to require. The transferring team should always review most recent CXR, and when significant changes to oxygenation or ventilation occur, a CXR should be repeated. If a pneumothorax is present a chest drain is indicated. Positive pressure ventilation can convert even a small simple pneumothorax into a tension pneumothorax. When
Breathing The child must be adequately ventilated and oxygenated during transfer. If positive pressure ventilation is required, this will often involve lung protective strategies, allowing for permissive hypercapnia. Important exceptions to this are the child with pulmonary hypertension or when neuroprotection is needed. On both occasions a tight control of PaCO2 within the normal range is desirable. Age and pathology-specific parameters are beyond the scope of this review. Specific advice should be obtained from the PIC consultant involved in the care of the child. Adequacy of ventilation will be confirmed by blood gas analysis (BGA) before departure (with the exception of PaO2 measurement, venous and capillary samples are adequate for BGA). The difference between
Figure 2 CATS ETT strapping (a modification of the Melbourne strapping). Pre-cut tape as demonstrated. Position the ETT at the corner of the mouth. Place the first tape on the same side, with the top “leg” going across below the nose, and the bottom “leg” wrapping around the ETT. The second tape will start from the opposite side. This time the bottom “leg” goes across under the bottom lip, while the top “leg” will go across below the nose until it reaches the ETT and wraps around it. The third tape secures the previous two tapes in place. A brief disconnection of the ETT from the ventilating circuit is required in order to introduce the third tape.
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transferring a child with a chest drain, a similar sized chest drain should be available should the chest drain become dislodged. A bagging circuit, with a self-inflating bag and an appropriate size face mask should be within reach throughout the transfer. It must be emphasized that the child should be ventilated via a transfer ventilator during the journey. Hand bagging on an interhospital transfer should be saved for emergencies and is not an acceptable routine practice.
maintain ductal patency at 10 nanograms/kg/minute should be commenced, observing for possible side effects (see Table 2) and managing them appropriately. In practice side effects tend to occur at infusion rates greater than 10 nanograms/kg/minute. However, if clinical improvement does not occur, and following discussion with the regional centre, the infusion rate may need to be increased, accepting and being prepared to manage any side effects of the treatment.
Circulation
Disability
The team should be familiar with the age-appropriate heart rate and an age and pathology-specific target blood pressure should be agreed. The child should be adequately fluid resuscitated and inotropes, if required, should be started before transfer. The transferring team should have a clear idea of fluid status following resuscitation and have a plan for the next intervention to support the circulation if needed. The haemodynamic status should be monitored continuously. Adjustment to infusion rates, and further fluid boluses can be given during transfer as necessary. Invasive venous and arterial pressure monitoring are helpful, but are not mandatory. They should never delay a time-critical transfer. At least one well secured IV access site must be available in any child being transferred, and a minimum of two sites if the child is ventilated. An intraosseous (IO) needle is an effective alternative if access is difficult and will provide access to a central circulation. To facilitate access to the IV access it is helpful to attach an extension to a venous cannula adding a three-way tap at its distal end. The second port on the three-way tap should be attached to a 500 ml bag of 0.9% sodium chloride solution, so that fluid boluses could be drawn up and administered without delay. The third port should be left free for administration of any other IV drugs as needed. In this way the site can be used without the practitioner needing to leave their seat in the ambulance.
The neurological status, including Glasgow Coma Score (GCS), pupillary size and response to light should be assessed and documented before transfer. If the child is sedated, the GCS before sedation was started must be documented. Pupils are to be rechecked on arrival at the receiving unit or sooner if clinically indicated. The child should be clinically monitored for seizures during transfer. In a sedated and muscle relaxed child unexplained tachycardia and dilated pupils may be the only clue. The team should have a low threshold for anti-seizure treatment in a child at risk of fitting e.g. prior seizures or known intracranial pathology. Adequate sedation and muscle relaxation should be used for the child’s comfort, as indicated by the clinical scenario and to facilitate a safe transfer. There is some controversy as to whether a continuous infusion or boluses of muscle relaxant should be used. It is our preference to use a continuous infusion to facilitate a safe transfer. Both sedation and muscle relaxation may need adjusting during transfer. The team should plan for this and have access to the infusion pumps to adjust the infusion rates and have further muscle relaxant boluses already drawn up. Our practice is to use a combination of Morphine (10e40 mcg/kg/ hour IV) and Midazolam (1e2 mcg/kg/minute IV) for sedation in children on transfer and Vecuronium (1e2 mcg/kg/minute IV) for muscle relaxation. Drug calculators are available from most retrieval services’ websites that will advise on how to make up each infusion. Table 3 provides details on how to make up and use some of the most commonly required infusions. Glucose levels should be monitored and episodes of hypoglycaemia treated without delay with a bolus of 2e3 ml/kg of 10% glucose solution. A serum glucose level should be checked again after the intervention. A continuous glucose containing infusion should be running and if needed one should increase the infusion rate or concentration, to avoid further hypoglycaemic episodes. A period of hypoglycaemia can result in irreversible brain damage.
Fluid and electrolytes Children should be kept nil by mouth during transfer and maintenance IV fluids should be used. We find that solution containing 0.9% normal saline and 5% glucose running at 2/3 the full maintenance rate is a good starting point. This will avoid episodes of hypoglycaemia, fluid overload, and hyponatraemia. However, the composition and the rate of the fluid infusion used will need adjusting according to pathology, electrolyte status, and glucose requirement. Be aware that neonates, and children with liver or metabolic disorders are prone to hypoglycaemia and may require solutions containing a higher glucose concentration. Other electrolytes including potassium, calcium and magnesium should be supplemented as needed.
Completing the examination and child protection All children should have a clearly documented head-to-toe examination. The possibility of child maltreatment should always be remembered. While the safeguarding of children is everyone’s responsibility, a paediatrician with a higher level of training in the safeguarding of children should be involved when safeguarding concerns are present, or when the presentation is unusual or the aetiology is unclear, such as in the case of an infant presenting with an unexplained respiratory arrest. Always consider the safety of other siblings and involve social services if any concerns arise. Clear written documentation of examination findings, including a body map and a record of any early conversations with family members is essential. When
A note about the collapsed neonate In neonates up to 4 weeks of age presenting with oxygen refractory cyanosis or acute cardiovascular collapse the diagnosis of a duct dependent circulation should be considered. While an echocardiograph examination performed by an appropriately skilled person is helpful, it is often not available, and so empirical treatment should be started before a positive diagnosis is made. A Dinoprostone (prostaglandin E2) infusion to open and/or
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SYMPOSIUM: INTENSIVE CARE
monitoring, ventilator, pumps, suction, defibrillator hold sufficient charge for the duration of the transfer. It is our practice to prepare a separate patient specific airway bag (Table 1) and drug bag (Table 4). These will have weight, age and pathology-specific equipment and drugs so as to avoid any delays in dealing with clinical developments during the transfer.
Using a Dinoprostone infusion Dinoprostone (prostaglandin E2) Preparation: C
15 micrograms/kg body weight of Dinoprostone (prostaglandin E2) to a total volume of 50 ml using 5% glucose as diluent
Administration:
How much oxygen should I take?
Dinoprostone infusion can run via a peripheral venous line C When made to the above concentration, 1 ml/hour delivers 5 nanograms/kg/minute C Start the infusion at a rate of 10 nanograms/kg/minute (2 ml/hour) Higher doses up to 50 nanograms/kg/minute may be necessary to open a closed duct but this should be discussed with the Paediatric Cardiologist/Cardiac Intensivist C
The formula used to calculate the oxygen requirement for transfer assumes that 100% oxygen is needed for the duration of the transfer. The key variables to be included in the calculation are: The duration of the transfer in minutes, from the moment one disconnects from the wall oxygen supply, until reconnecting to the wall oxygen supply at the destination. The number of litres per minute of gas flow needed. In a ventilated child this will usually approximate the child’s minute volume. One important exception is the babyPACÔ ventilator by Smiths Medical which is commonly used to ventilate infants on transfer. This ventilator when used in the Active PEEP mode consumes 11 litre/minute of fresh gas, irrespective of the other ventilator settings. When respiratory support devices, other than ventilators, are used the gas flow can be significantly higher. For example, 15 litre/minute through a non-rebreather face mask.
Side effects: C C C C
Hypotension Hypoglycaemia Apnoea (More common with doses >10 nanograms/kg/minute Fever
Table 2
examining the child on the PICU at the receiving hospital, it is often difficult to determine which findings are the results of the resuscitation efforts, and which ones were present on admission to the local hospital.
The drug bag Equipment The drug bag Adrenaline minijet Crystalloid for fluid resuscitation (0.9% sodium chloride solution) Doses of muscle relaxant drawn up in syringes 10% glucose to manage episodes of hypoglycaemia Any IV infusion that may be needed (see Table 3) made up into 50 ml syringes 10% Calcium gluconate solution Phenylephrine Any other drug that are anticipated to be needed during the transfer
Hospitals, in which critically ill or injured children may be looked after, should have paediatric transfer bags that are checked regularly. An equipment list should be on the outside of these bags, and any necessary equipment not included should be highlighted (such as controlled drugs, or drugs kept in the fridge). An exemplary list can be found in chapter 24 of the 5th edition of the APLS manual. The transfer team must be familiar with the contents of the bags, as well as the use of other transfer equipment such as the transfer trolley, infusion pumps and the transfer ventilator. They should always ensure that all electrical equipment i.e.
Table 4
Common drug infusions Drug
Standard infusiona
Volume
Rate of infusion
Dose range
Morphine Midazolam Vecuronium
1 mg/kg in 50 ml 6 mg/kg in 50 ml 3 mg/kg in 25 ml for children <15 kg 40 mg in 20 ml for children >15 kg 15 mg/kg in 50 ml 15 mg/kg in 50 ml for children <5 kg 80 mg in 50 ml for children >5 kg 0.3 mg/kg in 50 ml via central line
50 50 25 20 50 50 50 50
1 ml/hour ¼ 20 mcg/kg/hour 1 ml/hour ¼ 2 mcg/kg/minute 1 ml/hour ¼ 2 mcg/kg/minute 0.06 ml/kg/hour ¼ 2 mcg/kg/minute 1 ml/hour ¼ 5 mcg/kg/minute 1 ml/hour ¼ 5 mcg/kg/minute 0.375 ml/kg/hour ¼ 10 mcg/kg/minute 1 ml/hour ¼ 0.1 mcg/kg/minute
0e40 mcg/kg/hour 0e4 mcg/kg/minute 0e4 mcg/kg/minute 0e4 mcg/kg/minute 0e20 mcg/kg/minute 0e20 mcg/kg/minute 0e20 mcg/kg/minute 0e0.5 mcg/kg/minute
Dopamine (centrally) Dopamine (peripheral) Adrenaline/Noradrenaline a
ml ml ml ml ml ml ml ml
All of the following can be prepared in either 0.9% sodium chloride solution, 5% or 10% glucose.
Table 3
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The formula to be used is as follows:
One should then decide the composition of oxygen cylinders that will provide the calculated litres of oxygen. While one should use the ambulance power and oxygen during transfer, these should not be taken into account in the calculation.
The number of Litres of Oxygen to be available for transfer litre ¼ 2 Duration of journeyðMinuteÞ Gas flow Minute
Figure 3 An example of a pre-departure transfer checklist available on the Children’s Acute Transport Service.
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Monitoring
SUGGESTED READING AND RESOURCES Barry P, Leslie A. Paediatric and neonatal critical care transport. 1st edn. London: BML Books, 2003. Difficult Airway Society. Paediatric difficult airway guidelines. 2016 [Online] Available at: https://www.das.uk.com/guidelines/ paediatric-difficult-airway-guidelines (accessed 9 Oct 2016). Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents-second edition. Pediatr Crit Care Med 2012; 13(supp 1): S1e82. Kleinman ME, Donoghue AJ, Orr RA, Kissoon N. Stabilization and transport. In: Shaffner DH, Nichols DG, eds. Rogers’ textbook of pediatric intensive care 5e. Lippincott Williams and Wilkins, 2015; 348e62. Lampariello S, Clement M, Aralihond AP, et al. Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice. Arch Dis Child 2010; 95: 681e5. Ramnarayan P, Thiru K, Parslow RC, Harrison DA, Draper ES, Rowan KM. Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study. Lancet 2010; 376: 698e704. Tasker RC, Morris KP, Forsyth RJ, Hawley CA, Parslow RC. Severe head injury in children: emergency access to neurosurgery in the United Kingdom. Emerg Med J 2006; 23: 519e22.
It is not possible to continuously clinically evaluate a patient during transfer. Therefore, continuous monitoring that is easily visible to all team members is essential. All alarms should be set to age and pathology appropriate levels. The minimal monitoring to be used on all paediatric transfers includes oxygen saturation, ECG, NiBP, EtCO2 (if mechanically ventilated) and temperature. EtCO2 should be monitored during all transfers of ventilated children. It will guide ventilation and serve as a continuous reassurance that the ETT is in the trachea. In the smallest neonates, EtCO2 may add clinically significant respiratory dead space. On the rare occasions when this is demonstrated to impede ventilation, EtCO2 may be removed from the circuit. This should be done following discussion with an experienced consultant. In these situations the EtCO2 probe should still be readily available so that it can be introduced if ventilation or ETT position are a concern. The child’s temperature should be monitored continually. In neonates, the relatively high ratio of body surface area to weight, means that they are more prone to hypothermia.
Packaging and the journey All lines, catheters, tubes and drains should be safely secured before transfer. The child should be restrained using age and size appropriate restraints. Ensure that the ambulance is warm and utilise other warming adjuncts, especially when transferring neonates, such as the CosyTherm warming mattress or a single use TransWarmerÒ. Remember that in neonates, the head can be a significant source of heat loss and should therefore be covered. When requesting an ambulance, one should indicate the time urgency, and the type of transfer equipment (most importantly the transfer trolley) the team is using. This will ensure that the correct ambulance is sent in a timely manner. When deciding on the use of blue light and high speed driving, one ought to weigh the benefits of the time saved vs a more bumpy transfer and the risks to the team and patient. Using blue lights to negotiate heavy traffic may be warranted, high speed driving almost never is. One or both parents should be offered to join the transfer. However, this is at the discretion of the transferring team. If a parent is travelling with the ambulance, the team should take the time to explain the possibility of clinical deterioration while enroute, and what the parent is expected to do if the ambulance has to stop so that the team can deliver further treatment. Once the patient is packaged and the team is ready to depart, a pre-departure checklist should be used to ensure that nothing is missed (Figure 3).
SELECTED UK RETRIEVAL SERVICES WEBSITES Children’s Acute Transport Service: www.cats.nhs.uk. South Thames Retrieval Service: www.strs.nhs.uk. Southampton and Oxford Retrieval Team: www.sort.nhs.uk.
Practice points C
C
C
C
Summary C
The optimal transfer of very sick children requires the right people and the right preparation. The use of checklists and preparation can assist greatly in what is often a stressful and difficult situation. Discussion with the local PIC team can also be really helpful as they may prompt treatments or actions that had not been considered. We find that a structured approach and strict attention to detail can reduce the risks associated with transfer of a critically ill or injured children. A
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C
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With the centralization of paediatric critical care and other specialist services into regional centres, the need to transport children has increased. Whenever possible the transport of critically ill or injured children should be done by PIC specialist teams. The approach to the stabilization and transport of children should be done in a systematic way, following an ABC approach. Children should be stabilized and their condition optimized as much as possible before the transport, as clinical interventions during transfer is difficult and carries additional risks. Any interventions considered should be weighed against the implications of delaying transfer. Any intervention that is likely to improve outcome should be prioritized. The team should anticipate possible complications and have an agreed plan in place. There is much to remember and the use of checklists is advised.
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Transport of the critically ill child
or more commonly because the child’s condition is deemed to be time-critical. The commonest reasons for a time-critical transfer include an expanding intracranial mass lesion (e.g. extradural haematoma), a blocked ventriculo-peritoneal shunt or a general surgical emergency (e.g. small bowel volvulus). The above figures relate to inter-hospital transfers, however there are many more intra-hospital transfers of critically ill patients as well as inter-hospital transfer of non-critically ill children which are more often than not done by non-PIC specialist teams, though they carry many of the same risks. While transfer can be done on land air or sea, land transfer using an ambulance is by far the most common, and is the one we will focus on here.
Avishay Sarfatti Padmanabhan Ramnarayan
Abstract With the centralization of specialist services into a limited number of hospitals across the UK, an increasing number of children require an inter-hospital transfer. In 2014, 6000 critically ill or injured children were transferred between hospitals in the UK. While most of the transfers are done by specialist teams, as many as 23% are done by nonspecialist teams. These patients are some of the sickest children. It is while in transit that these patients are most at risk, and the transferring team is most exposed. To achieve a smooth and safe transfer it is important that the appropriate team with the relevant skills undertakes such transfers. The patient’s condition should be optimised before transfer and any likely difficulties are anticipated, and that the transferring team is prepared to act to resolve any complications swiftly and effectively. In this review we will attempt to offer our approach to the safe transfer of the critically ill child.
Stabilisation and preparation for transfer Unwell children should be stabilized prior to transfer. Most PIC transfer services in the UK have clinical management guidelines for the common presentations available on-line (see Further reading). Any interventions that are likely to improve outcome should also be done prior to transfer. There are, however, occasions, when definitive treatment can only be given at a specialist centre, and delaying transfer is likely to be deleterious. An example is the child with an expanding intracranial haematoma who requires a neurosurgical intervention. In such instances, any intervention considered should be weighed against the harm that may come from delaying transfer. When stabilizing and preparing a child for transfer, a system based approach is helpful. There should be clear leadership, with the key goals clear to all team members. Different aspects of the management should be delegated within the team so that the work can be done in parallel, minimising delays. Throughout the process of stabilization and preparation for transfer, communication with the regional PICU/PIC transfer service should be maintained, so that the PIC clinician can offer advice on clinical management, and make the necessary preparations to receive the child at the regional centre. Some examples of our advice offered in some of the commoner clinical situations are given in Figure 1.
Keywords critical illness; critical injury; inter-hospital transport; paediatric intensive care; stabilization
Introduction The reorganization of Paediatric Intensive Care services in the UK into regional centres has increased the need to transfer children between hospitals. The Paediatric Intensive Care Audit Network (PICANet), an international audit network that collects information on all children admitted to Paediatric Intensive Care in the UK and the Republic of Ireland, found in its 2015 annual report that “just over half of all emergency admissions to paediatric intensive care units (PICUs) in the United Kingdom are for sick children who first present at their local hospital and require stabilisation and transport to a hospital with a PICU. Over 6000 very sick children were transported to PICU in 2014.” The report further found that 77% of paediatric critical care transfers were done by specialist Paediatric Intensive Care (PIC) teams, with the remaining 23% being done by a variety of other teams with varying skill sets. These children are some of the sickest paediatric patients with a crude mortality of 8%. The outcome of the critically ill or injured child is better when the transfer is carried out by a PIC specialist team. Transfer is done by local teams either because such a team is not available,
The first conversation Once the need to transfer a critically ill or injured child is established, the regional PIC retrieval service should be contacted, and the management of the child should be discussed. To provide useful advice the PIC consultant will require some basic patient demographics (including working weight), a working diagnosis, a brief history, therapeutic interventions already instituted and their effect, and the current clinical status. The person allocated to the task ought to be familiar with the case, have recent observations, results of relevant investigations, and a recent blood gas analysis at hand. It is preferable that conversations be undertaken between the most senior staff member available locally and the most senior PIC staff member available. The discussion should achieve the following: Provide the front line team with relevant clinical advice for ongoing management. Reach a joint decision about the need for secondary transfer, and the destination. Establish who should undertake the transfer and the time scale for departure.
Avishay Sarfatti MRCPCH BMBCH MA, Specialist Trainee in Paediatric Intensive Care Medicine, Children’s Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Conflict of interest: none declared. Padmanabhan Ramnarayan FRCPCH FFICM MD, Consultant Paediatric Intensive Care Medicine, Children’s Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Conflict of interest: none declared.
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SYMPOSIUM: INTENSIVE CARE
Asthma
Sepsis
•Use PEEP of 4-6 cmH2 0 •PIP < 35 cmH20 •Avoid breath stacking by using a slow respiratory rate to allow a prolong expiratory time •Permissive hypercapnia as long as pH is >7.2 •Physiotherapy and endotracheal suctioning •Manual chest decompression by experienced personnel if breath stacking is a problem •Avoid Morphine / Atracurium infusions due to associated histamine release •Intubate early (once 40ml/kg of fluid given) as risk of pulmonary oedema is high • High risk of cardiovascular instability at the time of intubation • Use Ketamine and Fentanyl for induction •Have fluid boluses and inotropes ready •Use appropriately sized cuffed ETT. In severe sepsis, high PEEP / HFOV may be needed to overcome pulmonary oedema •Do not delay inotropes due to difficult IV access. Obtain early IO access
Brain injury
•Avoid hypoxia / hypotension •Tight control of PaCO2 within normal range •Ensure well sedated and paralysed to avoid rise in ICP •Use boluses of Fentanyl 2-5mcg/kg for any procedures such as suctioning • Target a high normal BP •Use hypertonic saline 3ml/kg of 2.7% Saline to manage episodes of intracranial hypertension •Avoid hypoglycaemia / hyperthermia •Transfer to a neurosurgical centre without delay
BronchioliƟs
•Try High flow humidified oxygen or CPAP •Intubate for worsening respiratory failure or apnoeas •But remember that apnoeas could be a sign of CNS pathology i.e. meningitis, intracranial haemorrhage •Suction and physiotherapy
Pulmonary Hypertension
•Sedate and paralyse •Aim Sats >95% •Aim normal pH 7.45 and PaCO2 4-5 kPa •Aim for high - normal BP •Consider need for inhaled Nitric Oxide (iNO)
Figure 1 Management considerations of common paediatric emergencies.
Determine which intervention should be done prior to transfer, and which ones should be postponed so as not to delay the transfer. In the event that the local team will be undertaking the transfer, likely complications and their management should be discussed. The conversation should be done in such a way as to allow the parallel ongoing clinical management of the child, and should not take key personnel away from the bedside.
available and working and that key steps are not missed. The checklist should include: The choice of induction agent and neuromuscular blocking agents. This should be guided by the clinical scenario. We find that Ketamine (2 mg/kg IV) Fentanyl (2e5 mcg/kg IV) for induction, followed by Rocuronium (1 mg/kg IV) is suitable on most occasions. They provide optimal intubating conditions rapidly, have an acceptable side effects profile, and are relatively cardiovascularly stable. Previous concerns that Ketamine causes a spike in intracranial pressure have been refuted. Preparation for potential haemodynamic instability. Fluid boluses and inotropes are to be drawn up and ready for use for all intubations. A naso/oro-gastric tube. This is a very useful adjunct to tracheal intubation in young children. A stomach distended with air will impede ventilation significantly in this group of patients. A plan for the management of a difficult airway should be clear to all. It should be in line with Difficult Airway Society guidelines. Identification and location of the appropriate sized laryngeal mask airway (LMA) before attempted intubation. Doing so as an emergency when dealing with a difficult intubation will add unnecessary stress. While some controversy still exists regarding the use of cuffed endotracheal tube (ETT), it is our practice to use cuffed ETT on
The team The transferring team should include a medical doctor or a specialist nurse practitioner with advanced airway skills and experience in paediatric intensive care and critical transfer, and an intensive care nurse who is experienced in inter-hospital transfers. Both should be familiar with the transfer equipment. A driver familiar with the transfer ambulance is a part of the team.
Airway The child must have a safe airway for the duration of the transfer. A low threshold for elective tracheal intubation before transfer should guide management. Intubation during transfer carries a significant risk and should be avoided if possible. A paediatric intubation checklist should be used. This will bring the team together, ensure that all necessary equipment is
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most occasions, so long as the ETT internal diameter is greater than 3.0 mm. Children are PEEP-dependent and therefore do not tolerate a leak around the ETT. If necessary the cuff can be deflated. After successful intubation the ETT should be secured in a safe way. Adult ETT ties are insufficient. Children have a shorter trachea than adults and small movements can result in endobronchial intubation, or worse, a dislodged ETT. It is our practice to use a modification of the Melbourne strapping to secure all ETTs on transfer (see Figure 2). End-tidal carbon dioxide (EtCO2) monitoring will ensure the early recognition of any displaced ETT and for that reason its use should be mandatory in the transfer of intubated children. If the intubation was not done by the transferring team, the details of the intubation including drugs used, grade of airway on laryngoscopy and any difficulties encountered should be familiar to the transferring team. A post-intubation chest radiograph (CXR) should always be done and the position of the ETT noted. The optimal ETT position is when the tip is at the level of T2 (providing the child’s head is in the neutral position when chest radiograph is taken). While the recommendations for cervical (C-)spine immobilisation have changed over the last few years any sedated and paralysed trauma patients should have their C-spine immobilised during transfer. Lastly, a patient specific airway bag should be prepared (Table 1) and readily available throughout the journey.
The airway bag The Airway Bag e all equipment should be age and weight appropriate A selection of ETT e the same size as used as well as one size up and one size down Suction catheters e a Yankauer suction catheter and several ETT suction catheters Appropriate size laryngoscope blade and two handles An oropharyngeal airway (Guedel) A laryngeal mask airway (LMA) A face mask Bagging circuit A self-inflating bagging circuit Tapes to secure an ETT Magill forceps Table 1
the EtCO2 and arterial PaCO2 should be noted. Any further changes on transfer will be guided by oxygen saturation and EtCO2 monitoring. All ventilated children should have a gastric tube sited and on free drainage as decompressing the stomach aids ventilation and prevents regurgitation. Most children with lung pathology will benefit from physiotherapy, aimed to remove secretions from the airway and recruiting atelectatic segments of lung. Whenever possible a paediatric physiotherapist should be asked to aid in this. If not available, this may need to be done by the medical team at the bedside. Guidance on how to do this will be given by the regional PIC team. One should recognise that there are occasions when ventilation can only be optimised so much at the local hospital. These occasions are rare, and should be discussed with the regional PIC consultant, who may advise to transfer the child without further delay to an appropriate PICU for the level of organ support that the child is likely to require. The transferring team should always review most recent CXR, and when significant changes to oxygenation or ventilation occur, a CXR should be repeated. If a pneumothorax is present a chest drain is indicated. Positive pressure ventilation can convert even a small simple pneumothorax into a tension pneumothorax. When
Breathing The child must be adequately ventilated and oxygenated during transfer. If positive pressure ventilation is required, this will often involve lung protective strategies, allowing for permissive hypercapnia. Important exceptions to this are the child with pulmonary hypertension or when neuroprotection is needed. On both occasions a tight control of PaCO2 within the normal range is desirable. Age and pathology-specific parameters are beyond the scope of this review. Specific advice should be obtained from the PIC consultant involved in the care of the child. Adequacy of ventilation will be confirmed by blood gas analysis (BGA) before departure (with the exception of PaO2 measurement, venous and capillary samples are adequate for BGA). The difference between
Figure 2 CATS ETT strapping (a modification of the Melbourne strapping). Pre-cut tape as demonstrated. Position the ETT at the corner of the mouth. Place the first tape on the same side, with the top “leg” going across below the nose, and the bottom “leg” wrapping around the ETT. The second tape will start from the opposite side. This time the bottom “leg” goes across under the bottom lip, while the top “leg” will go across below the nose until it reaches the ETT and wraps around it. The third tape secures the previous two tapes in place. A brief disconnection of the ETT from the ventilating circuit is required in order to introduce the third tape.
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transferring a child with a chest drain, a similar sized chest drain should be available should the chest drain become dislodged. A bagging circuit, with a self-inflating bag and an appropriate size face mask should be within reach throughout the transfer. It must be emphasized that the child should be ventilated via a transfer ventilator during the journey. Hand bagging on an interhospital transfer should be saved for emergencies and is not an acceptable routine practice.
maintain ductal patency at 10 nanograms/kg/minute should be commenced, observing for possible side effects (see Table 2) and managing them appropriately. In practice side effects tend to occur at infusion rates greater than 10 nanograms/kg/minute. However, if clinical improvement does not occur, and following discussion with the regional centre, the infusion rate may need to be increased, accepting and being prepared to manage any side effects of the treatment.
Circulation
Disability
The team should be familiar with the age-appropriate heart rate and an age and pathology-specific target blood pressure should be agreed. The child should be adequately fluid resuscitated and inotropes, if required, should be started before transfer. The transferring team should have a clear idea of fluid status following resuscitation and have a plan for the next intervention to support the circulation if needed. The haemodynamic status should be monitored continuously. Adjustment to infusion rates, and further fluid boluses can be given during transfer as necessary. Invasive venous and arterial pressure monitoring are helpful, but are not mandatory. They should never delay a time-critical transfer. At least one well secured IV access site must be available in any child being transferred, and a minimum of two sites if the child is ventilated. An intraosseous (IO) needle is an effective alternative if access is difficult and will provide access to a central circulation. To facilitate access to the IV access it is helpful to attach an extension to a venous cannula adding a three-way tap at its distal end. The second port on the three-way tap should be attached to a 500 ml bag of 0.9% sodium chloride solution, so that fluid boluses could be drawn up and administered without delay. The third port should be left free for administration of any other IV drugs as needed. In this way the site can be used without the practitioner needing to leave their seat in the ambulance.
The neurological status, including Glasgow Coma Score (GCS), pupillary size and response to light should be assessed and documented before transfer. If the child is sedated, the GCS before sedation was started must be documented. Pupils are to be rechecked on arrival at the receiving unit or sooner if clinically indicated. The child should be clinically monitored for seizures during transfer. In a sedated and muscle relaxed child unexplained tachycardia and dilated pupils may be the only clue. The team should have a low threshold for anti-seizure treatment in a child at risk of fitting e.g. prior seizures or known intracranial pathology. Adequate sedation and muscle relaxation should be used for the child’s comfort, as indicated by the clinical scenario and to facilitate a safe transfer. There is some controversy as to whether a continuous infusion or boluses of muscle relaxant should be used. It is our preference to use a continuous infusion to facilitate a safe transfer. Both sedation and muscle relaxation may need adjusting during transfer. The team should plan for this and have access to the infusion pumps to adjust the infusion rates and have further muscle relaxant boluses already drawn up. Our practice is to use a combination of Morphine (10e40 mcg/kg/ hour IV) and Midazolam (1e2 mcg/kg/minute IV) for sedation in children on transfer and Vecuronium (1e2 mcg/kg/minute IV) for muscle relaxation. Drug calculators are available from most retrieval services’ websites that will advise on how to make up each infusion. Table 3 provides details on how to make up and use some of the most commonly required infusions. Glucose levels should be monitored and episodes of hypoglycaemia treated without delay with a bolus of 2e3 ml/kg of 10% glucose solution. A serum glucose level should be checked again after the intervention. A continuous glucose containing infusion should be running and if needed one should increase the infusion rate or concentration, to avoid further hypoglycaemic episodes. A period of hypoglycaemia can result in irreversible brain damage.
Fluid and electrolytes Children should be kept nil by mouth during transfer and maintenance IV fluids should be used. We find that solution containing 0.9% normal saline and 5% glucose running at 2/3 the full maintenance rate is a good starting point. This will avoid episodes of hypoglycaemia, fluid overload, and hyponatraemia. However, the composition and the rate of the fluid infusion used will need adjusting according to pathology, electrolyte status, and glucose requirement. Be aware that neonates, and children with liver or metabolic disorders are prone to hypoglycaemia and may require solutions containing a higher glucose concentration. Other electrolytes including potassium, calcium and magnesium should be supplemented as needed.
Completing the examination and child protection All children should have a clearly documented head-to-toe examination. The possibility of child maltreatment should always be remembered. While the safeguarding of children is everyone’s responsibility, a paediatrician with a higher level of training in the safeguarding of children should be involved when safeguarding concerns are present, or when the presentation is unusual or the aetiology is unclear, such as in the case of an infant presenting with an unexplained respiratory arrest. Always consider the safety of other siblings and involve social services if any concerns arise. Clear written documentation of examination findings, including a body map and a record of any early conversations with family members is essential. When
A note about the collapsed neonate In neonates up to 4 weeks of age presenting with oxygen refractory cyanosis or acute cardiovascular collapse the diagnosis of a duct dependent circulation should be considered. While an echocardiograph examination performed by an appropriately skilled person is helpful, it is often not available, and so empirical treatment should be started before a positive diagnosis is made. A Dinoprostone (prostaglandin E2) infusion to open and/or
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monitoring, ventilator, pumps, suction, defibrillator hold sufficient charge for the duration of the transfer. It is our practice to prepare a separate patient specific airway bag (Table 1) and drug bag (Table 4). These will have weight, age and pathology-specific equipment and drugs so as to avoid any delays in dealing with clinical developments during the transfer.
Using a Dinoprostone infusion Dinoprostone (prostaglandin E2) Preparation: C
15 micrograms/kg body weight of Dinoprostone (prostaglandin E2) to a total volume of 50 ml using 5% glucose as diluent
Administration:
How much oxygen should I take?
Dinoprostone infusion can run via a peripheral venous line C When made to the above concentration, 1 ml/hour delivers 5 nanograms/kg/minute C Start the infusion at a rate of 10 nanograms/kg/minute (2 ml/hour) Higher doses up to 50 nanograms/kg/minute may be necessary to open a closed duct but this should be discussed with the Paediatric Cardiologist/Cardiac Intensivist C
The formula used to calculate the oxygen requirement for transfer assumes that 100% oxygen is needed for the duration of the transfer. The key variables to be included in the calculation are: The duration of the transfer in minutes, from the moment one disconnects from the wall oxygen supply, until reconnecting to the wall oxygen supply at the destination. The number of litres per minute of gas flow needed. In a ventilated child this will usually approximate the child’s minute volume. One important exception is the babyPACÔ ventilator by Smiths Medical which is commonly used to ventilate infants on transfer. This ventilator when used in the Active PEEP mode consumes 11 litre/minute of fresh gas, irrespective of the other ventilator settings. When respiratory support devices, other than ventilators, are used the gas flow can be significantly higher. For example, 15 litre/minute through a non-rebreather face mask.
Side effects: C C C C
Hypotension Hypoglycaemia Apnoea (More common with doses >10 nanograms/kg/minute Fever
Table 2
examining the child on the PICU at the receiving hospital, it is often difficult to determine which findings are the results of the resuscitation efforts, and which ones were present on admission to the local hospital.
The drug bag Equipment The drug bag Adrenaline minijet Crystalloid for fluid resuscitation (0.9% sodium chloride solution) Doses of muscle relaxant drawn up in syringes 10% glucose to manage episodes of hypoglycaemia Any IV infusion that may be needed (see Table 3) made up into 50 ml syringes 10% Calcium gluconate solution Phenylephrine Any other drug that are anticipated to be needed during the transfer
Hospitals, in which critically ill or injured children may be looked after, should have paediatric transfer bags that are checked regularly. An equipment list should be on the outside of these bags, and any necessary equipment not included should be highlighted (such as controlled drugs, or drugs kept in the fridge). An exemplary list can be found in chapter 24 of the 5th edition of the APLS manual. The transfer team must be familiar with the contents of the bags, as well as the use of other transfer equipment such as the transfer trolley, infusion pumps and the transfer ventilator. They should always ensure that all electrical equipment i.e.
Table 4
Common drug infusions Drug
Standard infusiona
Volume
Rate of infusion
Dose range
Morphine Midazolam Vecuronium
1 mg/kg in 50 ml 6 mg/kg in 50 ml 3 mg/kg in 25 ml for children <15 kg 40 mg in 20 ml for children >15 kg 15 mg/kg in 50 ml 15 mg/kg in 50 ml for children <5 kg 80 mg in 50 ml for children >5 kg 0.3 mg/kg in 50 ml via central line
50 50 25 20 50 50 50 50
1 ml/hour ¼ 20 mcg/kg/hour 1 ml/hour ¼ 2 mcg/kg/minute 1 ml/hour ¼ 2 mcg/kg/minute 0.06 ml/kg/hour ¼ 2 mcg/kg/minute 1 ml/hour ¼ 5 mcg/kg/minute 1 ml/hour ¼ 5 mcg/kg/minute 0.375 ml/kg/hour ¼ 10 mcg/kg/minute 1 ml/hour ¼ 0.1 mcg/kg/minute
0e40 mcg/kg/hour 0e4 mcg/kg/minute 0e4 mcg/kg/minute 0e4 mcg/kg/minute 0e20 mcg/kg/minute 0e20 mcg/kg/minute 0e20 mcg/kg/minute 0e0.5 mcg/kg/minute
Dopamine (centrally) Dopamine (peripheral) Adrenaline/Noradrenaline a
ml ml ml ml ml ml ml ml
All of the following can be prepared in either 0.9% sodium chloride solution, 5% or 10% glucose.
Table 3
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The formula to be used is as follows:
One should then decide the composition of oxygen cylinders that will provide the calculated litres of oxygen. While one should use the ambulance power and oxygen during transfer, these should not be taken into account in the calculation.
The number of Litres of Oxygen to be available for transfer litre ¼ 2 Duration of journeyðMinuteÞ Gas flow Minute
Figure 3 An example of a pre-departure transfer checklist available on the Children’s Acute Transport Service.
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Monitoring
SUGGESTED READING AND RESOURCES Barry P, Leslie A. Paediatric and neonatal critical care transport. 1st edn. London: BML Books, 2003. Difficult Airway Society. Paediatric difficult airway guidelines. 2016 [Online] Available at: https://www.das.uk.com/guidelines/ paediatric-difficult-airway-guidelines (accessed 9 Oct 2016). Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents-second edition. Pediatr Crit Care Med 2012; 13(supp 1): S1e82. Kleinman ME, Donoghue AJ, Orr RA, Kissoon N. Stabilization and transport. In: Shaffner DH, Nichols DG, eds. Rogers’ textbook of pediatric intensive care 5e. Lippincott Williams and Wilkins, 2015; 348e62. Lampariello S, Clement M, Aralihond AP, et al. Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice. Arch Dis Child 2010; 95: 681e5. Ramnarayan P, Thiru K, Parslow RC, Harrison DA, Draper ES, Rowan KM. Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study. Lancet 2010; 376: 698e704. Tasker RC, Morris KP, Forsyth RJ, Hawley CA, Parslow RC. Severe head injury in children: emergency access to neurosurgery in the United Kingdom. Emerg Med J 2006; 23: 519e22.
It is not possible to continuously clinically evaluate a patient during transfer. Therefore, continuous monitoring that is easily visible to all team members is essential. All alarms should be set to age and pathology appropriate levels. The minimal monitoring to be used on all paediatric transfers includes oxygen saturation, ECG, NiBP, EtCO2 (if mechanically ventilated) and temperature. EtCO2 should be monitored during all transfers of ventilated children. It will guide ventilation and serve as a continuous reassurance that the ETT is in the trachea. In the smallest neonates, EtCO2 may add clinically significant respiratory dead space. On the rare occasions when this is demonstrated to impede ventilation, EtCO2 may be removed from the circuit. This should be done following discussion with an experienced consultant. In these situations the EtCO2 probe should still be readily available so that it can be introduced if ventilation or ETT position are a concern. The child’s temperature should be monitored continually. In neonates, the relatively high ratio of body surface area to weight, means that they are more prone to hypothermia.
Packaging and the journey All lines, catheters, tubes and drains should be safely secured before transfer. The child should be restrained using age and size appropriate restraints. Ensure that the ambulance is warm and utilise other warming adjuncts, especially when transferring neonates, such as the CosyTherm warming mattress or a single use TransWarmerÒ. Remember that in neonates, the head can be a significant source of heat loss and should therefore be covered. When requesting an ambulance, one should indicate the time urgency, and the type of transfer equipment (most importantly the transfer trolley) the team is using. This will ensure that the correct ambulance is sent in a timely manner. When deciding on the use of blue light and high speed driving, one ought to weigh the benefits of the time saved vs a more bumpy transfer and the risks to the team and patient. Using blue lights to negotiate heavy traffic may be warranted, high speed driving almost never is. One or both parents should be offered to join the transfer. However, this is at the discretion of the transferring team. If a parent is travelling with the ambulance, the team should take the time to explain the possibility of clinical deterioration while enroute, and what the parent is expected to do if the ambulance has to stop so that the team can deliver further treatment. Once the patient is packaged and the team is ready to depart, a pre-departure checklist should be used to ensure that nothing is missed (Figure 3).
SELECTED UK RETRIEVAL SERVICES WEBSITES Children’s Acute Transport Service: www.cats.nhs.uk. South Thames Retrieval Service: www.strs.nhs.uk. Southampton and Oxford Retrieval Team: www.sort.nhs.uk.
Practice points C
C
C
C
Summary C
The optimal transfer of very sick children requires the right people and the right preparation. The use of checklists and preparation can assist greatly in what is often a stressful and difficult situation. Discussion with the local PIC team can also be really helpful as they may prompt treatments or actions that had not been considered. We find that a structured approach and strict attention to detail can reduce the risks associated with transfer of a critically ill or injured children. A
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C
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With the centralization of paediatric critical care and other specialist services into regional centres, the need to transport children has increased. Whenever possible the transport of critically ill or injured children should be done by PIC specialist teams. The approach to the stabilization and transport of children should be done in a systematic way, following an ABC approach. Children should be stabilized and their condition optimized as much as possible before the transport, as clinical interventions during transfer is difficult and carries additional risks. Any interventions considered should be weighed against the implications of delaying transfer. Any intervention that is likely to improve outcome should be prioritized. The team should anticipate possible complications and have an agreed plan in place. There is much to remember and the use of checklists is advised.
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