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Transport - team preparation and management

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Guidelines

  1. Retrieval is indicated for sick children who need specialised skills, intervention, equipment or knowledge and any child requiring ventilation for more than 24 hours.
  2. Full information should be recorded on the PICU transport referral form, a copy of which is kept in the PICU.
  3. The transport is urgent if there is airway instability, septic shock, head injury, unstable cardiac or respiratory disease or severe asthma.
  4. Choice of transport:
    1. Road ambulances are used for retrievals within greater Auckland.
    2. Fixed wing aircraft are used to retrieve critically ill patients for distances > 250km, and are fast, able to be pressurised, and good in adverse weather.
    3. Helicopters are used for distances < 250km, are not pressurised, are costly, slower and more reliant on good weather conditions.
  5. Good communication between the referral hospital, PICU and retrieval team is essential at all times. Where possible, the PICU consultant will advise the referral hospital about management prior to the team arriving.
  6. All staff should be trained and have completed safety briefings prior to undertaking transport duties. No transport should proceed with a team who do not feel comfortable to do so. This should be discussed with the PICU consultant.
  7. The team should anticipate the worst scenario and take appropriate equipment, such as the servo ventilator, nitric oxide, and special drugs (prostaglandin, mannitol) or equipment (central lines).
  8. Oxygen required for transport can be calculated by the formula: Gas required = minute volume x 60 x duration of journey x 2.
  9. Two gas laws are important for air retrieval. They are Boyle's Law (P1V1=P2V2) and Dalton's Law (Pt=P1 +P2 + P3). The combined effect of these is that as you ascend, gas expands and there is a fall in saturations, pO2, temperature and humidity.

Management

  1. Good handover and documentation are essential.
  2. The team should prioritise interventions and discuss their plan prior to handling the patient.
  3. First principles are paramount, comprising ABC's and regular frequent review:
    1. Secure the airway, intubate if there are concerns about airway stability, level of consciousness or oxygenation.
    2. Prophylactic chest drains may be required in the presence of air leak, which will worsen with expansion at altitude. Humidification and suction are important en route, and ETT position and blood gas should be checked prior to departure.
    3. Good venous access requires two cannulae or a central line. Arterial lines should only be placed if required, as these may disconnect en route.
    4. Adequate fluid resuscitation should be given during stabilisation, prior to departure, with further fluid available for the journey.
  4. All fluid and infusions should be given via infusion pumps as air expansion in fluid bags may increase the rate of fluid administration.
  5. If inotropes are likely to be required, central access should be obtained prior to departure and infusions made up and connected.
  6. Normothermia is important, as transport craft may be cold. Warm blankets and hats should be used.
  7. Family members may accompany the patient at the discretion of the air or ambulance crew. It is important that family members are informed of the patient's status and the risks associated with transfer. If not accompanying, a contact number should be obtained.
  8. Prior to departure:
    1. prepare boluses, fluids, an airway bag and infusions to last the duration of the journey.
    2. adequate sedation and paralysis should be given, with extra boluses available for the trip.
    3. all cuffs (ETT, IDC) should be deflated (or filled with water) and all drains and tubes unclamped.
    4. PICU should be called to give an estimated time of arrival and to outline the condition of the patient, and treatment required (infusions, oscillator, dialysis)
  9. En route, as little intervention as possible should be performed. It is always advisable to "see something pink" rather than relying solely on monitoring.
  10. On arrival, the transport team is responsible for the patient until handover is given to the PICU staff, and the patient and all equipment and monitoring is transferred.

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Document Control

  • Date last published: 31 October 2005
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Brent McSharry
  • Editor: John Beca
  • Review frequency: 2 years