Pediatric Intensive Care Transport

Intensive Care
Jonathan Cu, MD
Pediatric Emergency Specialist
Neonatal and Pediatric Critical Care
Transport Specialist
Neonatal and Pediatric Intensive
Care Transport Unit
Neonatal and Pediatric
Intensive Care Transport Unit
Goal and Objectives
 Give a background on pediatric intensive care
 Understand the goals and principles of pediatric
 Identify the basic components of a pediatric
intensive care transport team
 Recognize factors involved in choosing various
modes of transport
Case 1
 37/F, pregnant, 28 weeks AOG
 2-week vacation in far flung rural area
 Went into preterm labor
 Brought to community hospital and delivered
 Outcome: preterm 28 weeks 800grams AGA
delivered via SVD, live baby boy, APGAR 4,6
Case 1
 Patient has poor activity, gasping, HR 140, pink
centrally but has poor distal perfusion, Temp 34C
sats 85%
 Problem: no local neonatologist/intensivist and
no ICU facilities
 Local doctor were able to thermoregulate, give
O2 support but has difficulty cannulating and
reluctant to perform endotracheal intubation
 Asking for help from tertiary referral centre
Case 2
 3/M vacation in a beach with family
 Near drowning, submerged for 5 minutes
 Initially HR 0
 CPR performed for 10 minutes with ROSC
 Paramedics arrived, intubated the patient and
transferred to a local hospital
Case 2
 Upon arrival in ED of a local hospital, having
hypotensive episodes and desaturations while
on ambubagging
 Problem: no local ICU facilities and no intensivist
 Called a tertiary referral centre asking for help
 What can we offer in a community hospital
 Who to talk to and how to refer to a tertiary
referral centre
 Who will arrange for an ICU bed
 Who will coordinate for a safe transfer
 What can we do for the patient while waiting for
help to arrive
Bahala na si…
Neonatal and Pediatric Intensive
Care Transport Unit
 Specialized service dedicated in providing
intensive care to critically ill child anywhere at
any time
 Provide expert clinical advise
 Clinical coordinator
 Emergency treatment and stabilization
 Bringing ICU to the patient
 Interhospital transport
 In the United States, Australia, UK and Canada,
hospital-based neonatal transport programs
were first created in the 1960s and 1970s
 Similar programs for older infants and children
emerged in the 1980s
 Became well-developed in countries with a
centralized healthcare system
 Neonatal-pediatric transport programs part of
the continuum of care in a system of emergency
medical services for children
 They provide a safe, therapeutic environment for
pediatric patients who must be transferred
between health care institutions under urgent or
emergent circumstances
Diagnostic Categories Of Children
Specialized transport team
vs. Paramedics
Specialized transport
 Primary retrievals
 Secondary/hospital
 Not equipped
 Adequate planning and
 Not trained in handling
intensive care
 Scoop and run principle
 Intensive experience in
ICU/Emergency care
 Early goal-directed
 Bringing ICU to the
The Tortoise and the Hare
The Golden Hour
 Concept originated in 1973 by Cowley et
 Referred to Army helicopter use
 Goal for soldiers to be within 35 minutes of
definitive life-saving care
 Stated a 3 fold increase in mortality with
every 30 minutes away from ‘definitive
 No available data to support claim
 Resulted in less field intervention in favor
of speed of transport
 Interventions on transport in 1973, not
comparable to our capabilities today
Pediatric arrest
 Primary cardiac arrest in infants and children is
 Pediatric cardiac arrest is often preceded by
respiratory failure and/or shock and it is rarely
 Early intervention and continued monitoring can
prevent arrest
 The terminal rhythm in children is usually
bradycardia that progresses to PEA and asystole
 Septic shock is the most common form of shock
in the pediatric population
 80% of children in septic shock will require
intubation and mechanical ventilation within 24
hours of admission
Interesting facts…
 EMS programs for paramedics offers <10 hours
pediatric training
 No pediatric blood pressure cuffs (24%)
 No pediatric airway equipments (79%)
Seidel JS et al. Circulation 1986
Interesting facts…
According to AAP, average EMS
provider sees:
 1 peds BVM case q 1.7 years
 1 peds intubation q 3.3 years
 1 peds IO line q 6.7 years
Interesting facts…
 Paramedics were less confident in assessing vital
signs for <2 years old
 Children <14 years old undertreated as
compared with adults
Gausche M et al, Acad Emerg Med 1998
 Twice as many patients transported by standard
paramedic/ambulance service died in the first
12 hours after admission
Bellingan G et al, Intensive Care Med 2000
Orr RA et al, Pediatrics 2009
Specialized Pediatric Transport
 Fewer unplanned events (61% vs. 1.5%), 38 times
higher for patients transported by nonspecialized
 Significantly lower mortality rate (23% vs. 9%), >2
times higher for patients transported by
nonspecialized team
Orr RA, et al, Pediatrics 2009
Intensive Care Med 2004
Intensive Care Med 2004
Intensive Care Med 2004
Siriraj Hospital (Thailand)
 Retrospective review of interhospital transport
 Total number transported from 2001 to 2003: 36
 All road transfers
 Accompanying medical personnel: nurses (55%),
the rest paramedics
 63.9% intubated, 28% ongoing inotropes
J Med Assoc Thai 2005
Siriraj Hospital (Thailand)
 Upon arrival, none of the patients had any
record on important patient’s data (no vital signs
monitoring, oxygen saturation or adverse events)
 77.8% needed prolonged PICU stay
 31% mortality rate
J Med Assoc Thai 2005
Goal of Pediatric Intensive Care
 Early direction and initiation of advanced care
 Treatment and monitoring with the expected
expertise and capabilities of the tertiary care
center while the patient is still in the referring
 Improve safety of the transport and patient
Initiation of ‘definitive’ care
 Definitive care begins with the arrival of the
transport team
 Early goal directed treatment improves
 Needs to begin with the local emergency
departments and continue with the transport team
 Early aggressive interventions to reverse shock can
increase survival by 9 fold if proper interventions
are done early!
 Hypotension and poor organ perfusion worsens
“Further improvement in the outcome of critical illness
is likely if the scoop-and-run mentality is replaced
by protocol driven, early goal-directed therapy in
the pretertiary hospital setting”
Stroud et al., 2008
Initiation of ‘definitive’ care
 Ramnarayan (2009)
 Urgent vital interventions such as CPR,
intubation or central venous access required
in the first hour after arrival in an ICU
 May indicate that inadequate stabilization
was completed during transport
 McPhearson and Graf (2009)
 Attention to small details makes significant
difference in pediatric transport
 Securing ETT
 Early recognition and treatment of shock
 Adequate IV access
Essential components
 Dedicated team proficient at
providing neonatal and/or
pediatric critical care during
Essential components
 Medical control by qualified physicians
 Ground and/or air ambulance
 Communications/dispatch capabilities
 24/7 availability
 Written clinical and operational
Essential components
 Quality and performance
improvement activities
 Administrative resources
 Institutional endorsement and
financial support.
Med Control Physician
 PEDS ER or PICU consultant with sufficient
knowledge and experience in transport
 Accepts pt, consults subs
 Sends appropriate team
 Directs stabilization
 Provides ongoing direction to transport team
How does it work?
Team Composition
 Depends on the patient’s needs
 determined in consultation with the
team and medical control
 Dedicated pool of qualified
physicians, nurses, paramedics and/or
respiratory therapists
Team Composition
 Retrieval specialist
 Critical care nurse / Nurse Practitioner
 +/- Respiratory therapist
 Ambulance driver/pilot
Team Composition
 A team member’s degree is less
important than his or her ability to
provide the level of care required
 Critical care during transport
conditions is significantly different from
an ICU or ED
Team Composition
 Should not be assumed that a health
care professional who is competent in
the ICU or ED will function equally well
in a mobile environment
 Modified Stretcher/Incubator system
newborn, infant, toddler, adult system
 Backpacks - ABCs
 Medication bag – inotropes, surfactant, etc…
 Syringe / infusion pumps with long battery life
 +/- nitric oxide machine
 Ambulance fitted with oxygen(4500L) and air(4500L),
Zoll defibrillator, Laerdal electric suction,
transilluminator, charger, refrigerator
 Communication devices
Mode of Transport
 Road Ambulance
 Rotary wing
 Fixed wing
Vehicle selection
 Ground – space and option to stop
 Fixed Wing – stability in bad weather
 Helicopter – land at scene, speed
Determining mode
 Four critical steps necessary for
selection of the optimal mode
 Evaluation of the current patient status
 Evaluation of care the required before
and during transport
 Urgency of the transport
 Logistics of a patient transport (e.g., local
resources available for transport, weather
considerations, and ground traffic
Ground Vs Air
 Beyond 100 miles, a ground may become
inefficient, costly to operate, and time
 Helicopter is used for up to 150 mile radius
 Fixed wing greater than 150
Ground Vs Air
 Distance to the closest appropriate facility is too
great for safe and timely transport by ground
 The potential for transport delay that may be
associated with the use of ground transport
(e.g., traffic and distance) is likely to worsen
the patient's clinical condition
Key Points
 Good communication = good decision-making
 Adequate resuscitation and proper stabilization
prior to transport
 Expect for the worst case scenario
Retrieval team’s worst nightmare –
Resuscitation / Arrest en route
Back to Case 1
 Fortunately, there is an available Neonatal and
Pediatric Intensive Care Transport Unit
 Conference call made with the neonatologist
 Referring physician advised to keep the baby
thermoregulated, instructed to use neopuff and
gave step by step instruction on how to put an
umbilical line to provide fluids and glucose while
the retrieval team was being mobilised.
Back to Case 1
 Upon arrival, patient was intubated, sedated, given
surfactant and connected to transport ventilator.
 Vitals: HR 140 BP 70/40 sats 95%
Temp 36.5 C CRT 2secs
 CXR done
 Blood gas taken with iSTAT
 Transferred to transport incubator
 Brought back to tertiary referral centre uneventful
Back to Case 2
 Conference call with PICU was arranged while
to retrieval team went en route
 GCS 3, HR 120, intubated on ambubagging, BP
70 systolic, CRT 3-4 secs.
 Advised to give bolus of 20ml/kg pNSS and to
start Dopa at 10mcg/kg/min
 BP and perfusion improved
Back to Case 2
 Team arrived within 1 hour
 Hooked to transport ventilator, sedated and
 oxygen saturation improved and blood gas
 Central line inserted for IV fluids and inotropes
 Arterial line inserted for BP monitoring
 Maintained on Temp 33-34 C
 Transported back to tertiary referral centre uneventful
 Stayed in PICU for 7 days and transferred to regular
bed after with no neurologic deficit
Do we need a Specialized
Transport System?
Utility vs Futility
 The benefits of transport must outweigh the risks
for the patient
limited space, equipment, staff
separation from family
 The risks/costs of transport must be justified
 The approximate cost of a medically
configured ground ambulance is
approximately $150 000 to $350 000,
depending on the manufacturer and
model selected
 The annual maintenance and fuel
costs might range from $10 000 to $25
000 per vehicle
 Single-engine helicopter A-Star or Bell
407 averages $2 million.
 A light twin-engine helicopter EC145
and Bell 430, both medium-sized twin
engine helicopters, cost between $4
and $6 million
 While a large twin-engine helicopter
about $1-2 million more
 Pilot salaries range from $60,000 to
$85,000 annually; a staff of four is
required to cover 24/7
 Financial concerns include fixed and
variable costs
 Fixed costs include insurance, taxes, crew
costs, overheads, interest, hanger fees
and capital equipment
 Variable (hourly) costs vary directly with
the number of hours flown. These costs
include fuel and oil, scheduled
maintenance labor, etc
Cost Effectiveness
 Cost effective for a centralized health care
 Composed of a single retrieval unit covering for
the whole state
 Expensive to maintain but less costly than to put up
pediatric ICUs in rural hospitals
 US retrieval system mostly hospital-based
 Improved patient outcome
 Patient transport safety
 Less expensive to maintain
What if Case 1…
Grandson of a business
What if Case 2…
Child of a
Thank you!

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