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Transportation of Critically Ill Patients

83

 

Amit Varma and Sandeep Dewan

 

A 57-year-old male patient was admitted to the emergency department with complaints of abdominal pain and recurrent vomiting. He was found to be in a state of septic shock. After the initial resuscitation, his abdominal examination was remarkable for abdominal distension with absent bowel sounds. The ultrasonography report of the abdomen was inconclusive, and he was shifted to the radiology department for a contrast-enhanced CT scan of the abdomen. He was still on inotropic and vasopressor support.

The ideal way to consider transport of a critically ill patient is as a “mobile ICU environment.” Attention to details during transport ensures patient safety.

83.1Intrahospital Transport

Step 1: Evaluate the need for transfer

The most important initial step is to evaluate the potential benefit which may be derived by shifting the patient against the risks involved.

The aim or purpose and the justification to transport should be noted in the case record.

The potential risks can be minimized by careful planning of the procedure and utilization of available equipment and personnel.

A multidisciplinary team of the physician, nurses, paramedical staff, and transport coordinator is required to plan and coordinate the process.

A. Varma, M.D. (*)

Critical Care Medicine, Fortis & Escorts Heart Institute and Research Centre, New Delhi, India e-mail: amit.varma@fortishealthcare.com

S. Dewan, DA, D.N.B.

Critical Care Medicine, Fortis Escorts Heart Institute, New Delhi, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,

667

DOI 10.1007/978-81-322-0535-7_83, © Springer India 2012

 

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A. Varma and S. Dewan

 

 

Transport of the patient should not be undertaken in the following circumstances:

Inability to provide adequate oxygenation and ventilation during transport or at destination, either by the manual resuscitator bag, portable ventilator, or standard intensive care unit ventilator.

Inability to maintain acceptable hemodynamic parameters during transport or at destination.

Inability to adequately monitor the patient’s cardiopulmonary status during transport.

Inability to maintain airway control during transport or at destination.

All the necessary members of the transport team are not present.

Receiving team is not ready.

Step 2: Pretransport coordination and communication

A physician-to-physician and nurse-to-nurse communication is required to plan the transport.

The team ensures that the receiving location is ready to receive the patient for immediate procedure and testing.

Documentation in the medical record should be done, which includes the indication of transport and the clinical status of the patient.

Step 3: Accompanying personnel

Minimum of two people, preferably one of them from the treating ICU team, should accompany a critically ill patient.

It is strongly recommended that a physician with training in airway management and advance cardiac life support accompanies the unstable patient.

The transport personnel should remain with the patient until return to the ICU.

Step 4: Equipment requirement

The equipment to be used during transport should be dedicated and should not be used anywhere else.

A blood pressure monitor, a pulse oximeter, invasive and noninvasive ventilators, and defibrillators.

Basic resuscitation drugs including epinephrine, nor epinephrine, antiarrhythmic drugs, vasopressin, muscle relaxants, sedatives, narcotics, analgesics, dextrose ampoule, and appropriate IV fluids.

Drip medications must accompany the patient.

All battery-operated equipments must be fully charged and should have adequate battery backup provision.

In mechanically ventilated patients, endotracheal tube position is noted and secured before and during transport and the adequacy of oxygenation and ventilation is reconfirmed.

No equipment or drugs should be placed over the patient. Most units will have custom-made shelves, which will fit on the beds or trolleys.

The monitors and/or ventilators should be properly secured with straps to the bed or shelves so that they do not fall on the patient.

83 Transportation of Critically Ill Patients

669

 

 

Step 5: Identifying high-risk patients

Patients in the following categories are at particularly high risk for deterioration during or after transport:

The mechanically ventilated patients, particularly those with requirement of high

positive end-expiratory pressure and FiO2 more than 0.5. Extra oxygen reserve for patients with high oxygen requirement should be kept.

Patients with high therapeutic injury severity score

Head-injured patients

Hemodynamically unstable patients requiring continuous infusion of dobutamine, or a continuous infusion of norepinephrine or other potent vasoactive agents

Step 6: Monitoring during transport includes the followings

ECG monitoring

Pulse oximetry

Periodic measurement of the blood pressure, pulse rate, and respiratory rate

Selective patients may benefit from capnography, continuous intra-arterial blood pressure monitoring, and intracranial pressure monitoring if required.

Step 7: Care during transport

Ideally, the patient should receive the same level of care as in the pretransport area.

Vital signs should be monitored and recorded at fixed intervals.

Use of memory-capable monitors should be used. This will allow documentation of data during transport.

Any adverse events should be noted and immediately acted upon.

There should be a designated senior physician available for consult in case of an adverse or critical event during transport.

Ideally, he/she should be available on-site and should be able to arrive at the destination area if required.

The transport team should be able to communicate with the designated person during transit as well as upon arrival at the destination in case of an emergency.

83.2Interhospital Transport

When a critical care patient requires resources, which are not available in the existing hospital, the patient will be transferred to a facility that has the required resources. Interhospital patient transfer will occur only when the benefits exceed the efforts. If needed, the resuscitation and stabilization of the patient should be carried out before the transport.

Basic requirements are the same for intraor interhospital transport. Interhospital transport requires more planning, more personnel, vehicle availability, consideration of altitude effects in air transport, weather condition, battery life of equipments,

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A. Varma and S. Dewan

 

 

backup equipment, oxygen supply, power supply, contingency plan in case of breakdown, and more documentation for medicolegal purposes.

Step 1: Take informed consent

An informed consent for interhospital transport must be taken from a competent patient, guardian, or legally authorized representative, if the patient is incompetent.

It includes a discussion of the risks and benefits of transfer.

It should be documented in the medical records before the transfer is done.

In case of life-threatening emergencies when an informed consent cannot be taken, the indication of transfer and the reason for not obtaining consent must be documented in the medical record.

Step 2: Communicate and coordinate prior to transport

The referring physician will contact the receiving physician and will explain the clinical condition to him/her.

The mode of transportation (ground/air) will be determined by the transferring physician based on the medical condition, the time savings, facilities available, and the medical interventions required.

The transport service will then be contacted to confirm its availability and coordinate the timing. A copy of the medical record including case summary and all relevant laboratory and radiographic data will accompany the patient.

Step 3: Decide on accompanying personnel

It is recommended that minimum of two people should accompany a critically ill patient.

The transport team leader should be a treating physician/intensivist/anesthesiologist with additional training in transport medicine.

It is strongly recommended that a physician with training in airway management and advance cardiac life support accompanies the unstable patient.

The transport personnel will remain with the patient until reaching the ICU.

There must be a clear chain of responsibility throughout the transfer. A proper handover from referring physician to transfer physician and then to receiving facility physician is essential.

Step 4: Choose transport equipment and medicines

When choosing the equipment, the following should be considered: size, weight, battery life, ability to fit to trolley railings, ability to function under condition of vibration, ease of use in poor light, and placement in restricted space.

Equipments should be adequately restrained and should be easily accessible to the operator.

Backup equipment may be desirable in some situation.

The recommended minimum transport equipments and medications are given in Tables 83.1 and 83.2.

Table 83.1 Recommended minimum transport equipments

Adult/pediatric bags—valve systems and oxygen reservoir

Adult and pediatric masks

Flexible adaptors to connect the bag valve system to the endotracheal/tracheostomy tube

End-tidal carbon dioxide monitors (pediatric and adult)

Infant mediumand high-concentration masks with tubing

Laryngoscope with blades with extra batteries

Endotracheal tubes with stylets

Magill forceps

Nasopharyngeal airways

Oral airways

Scalpel with the blade for cricothyroidotomy kit

Needle cricothyroidotomy kit

Water-soluble lubricant

Nasal cannulae

Oxygen tubings

Adhesive tape

Aerosol medication delivery system

Alcohol swabs

Arm boards

Arterial line tubings

Intraoseous needle

Blood pressure cuffs

Butterfly needles

Communications backups

ECG monitor/defibrillator with electrolyte pads and jelly

Flashlights with extra batteries

Heimlich valve

Infusion Pumps

IV fluid administration tubing

Y fluid administration tubing

Extension tubing

Three-way stopcocks

IV catheter (14–24G)

Intravenous solutions (1,000 mL, 500 mL of normal saline)

Irrigating syringe (60 mL), catheter tip

Kelley clamp

Hypodermic needles and syringes, assorted sizes

Normal saline for irrigation

Pressure bags for fluid administration

Pulse oximeter with multiple site adhesive or reusable sensors

Soft restraints for upper and lower extremities

Stethoscope

Suction apparatus and catheters

Surgical dressings and tourniquets

Trauma scissors

The followings are considered as needed: neonatal/pediatric isolette, spinal immobilization device, and transport ventilator

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Table 83.2 Recommended minimum transport medication

Adenosine (6 mg/2 mL)

Amiodarone (150 mg/3 mL)

Atropine (0.6 mg/mL)

Calcium chloride (1 g/10 mL)

Dextrose (25%/50%)

Digoxin (0.5 mg/2 mL)

Diltiazem (25 mg/5 mL)

Diphenhydramine (50 mg/1 mL)

Dopamine (200 mg/5 mL)

Epinephrine (1 mg/10 mL)

Furosemide (100 mg/10 mL)

Glucagon (1 mg vial)

Heparin (1,000 units)

Isoproterenol (1 mg/5 mL)

Labetalol (40 mg/8 mL)

Lidocaine (100 mg/10 mL)

Mannitol (50 g/50 mL)

Magnesium sulfate (1 g/2 mL)

Metroprolol (5 mg/5 mL)

Naloxone (2 mg/2 mL)

Nitroglycerine injection (50 mg/10 mL)

Nitroglycerine tablets (0.4 mg)

Nitroprusside (50 mg/2 mL)

Normal saline (30 mL) for injection Nor epinephrine (2 mL)

Phenobarbital (65 mg/mL or 130 mg/mL)

Potassium chloride (20 mEq/10 mL)

Procainamide (1,000 mg/10 mL)

Sodium bicarbonate (50 mEq/50 mL)

Sterile water (30 mL) for injection

Terbutaline (1 mg/1 mL)

Verapamil (5 mg/2 mL)

The following specialized/controlled medications are added immediately before transport as indicated:

Narcotic analgesics (e.g., morphine and fentanyl)

Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, and ketamine)

Neuromuscular blocking agents (e.g., succinylcholine, pancuronium, atracurium, and rocuronium)

Additional drugs should be added depending on specific circumstances (antiar-

rhythmic or antibiotics that need to be dosed during transport).

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