Presentation on theme: "Transport of the Critically Ill Child: The Essentials Allan de Caen MD FRCP Pediatric Critical Care Medicine Stollery Children's Hospital Edmonton, Canada."— Presentation transcript:
Transport of the Critically Ill Child: The Essentials Allan de Caen MD FRCP Pediatric Critical Care Medicine Stollery Children's Hospital Edmonton, Canada
Objectives Case illustration Starting the transport process: who, how, what team, and why… Stabilization pre-transport
Conflict of Interest Statement Medical Director of Stollery PICU Transport Team Co-Chair of CAPHC (National) Pediatric Interfacility Transport Steering Committee No Financial COI
A previously well 9 year old presents to a rural hospital with a 24 hour history of fever, malaise, myalgias. She has had increased lethargy and respiratory distress over the last 6 hours. Upon ER presentation, the child appears mottled, is acting confused, and has moderately increased work of breathing. Her ER vitals are T 39°C, HR 150, BP 70/50, RR 35, and a RA 02 saturation of 89%. It is apparent to the referral hospital team that her medical care will ultimately require tertiary care admission.
Starting resuscitation and calling for help Identify early whether the patient will require transfer, and call for help early (time to transport might be hours…) for RAAPID North for RAAPID South Air transport of critically ill children (or those at risk of being so) is coordinated through local Children's Hospital PICU (provincial dividing line at Red Deer) Pediatric Intensivst can not only facilitate getting help to the referral hospital (transporting team or otherwise), but supporting the referral center while help is en route
Pediatric Transport: Weighing Priorities Referring Hospital limited MD/ RN resources limited technical skills/ experience limited equipment Accepting Hospital MD/ RN resources abundant technical skills/ experience limitless equipment Patient Care Time to tertiary care Transport team composition Transport mode Disease specific issues
Who should transport the patient? Referral hospital/ regional team (MD/ RN/ Medic) Removing local resources Do they have setting specific cognitive and technical skills/ equipment? ALS/ adult critical care flight team (eg. STARS) Predominantly adult-focused Limited (non-trauma) pediatric experience Pediatric critical care Best option for critically ill child ( mortality) Limited resource Prolonged time to patient bedside (av min)
How is the decision made as to what kind of team transports? Patient acuity (acuity scores vs. gut feeling) Age (<5 years age vs. adolescence) Distance to tertiary care center Disease specific Expanding intracranial mass Traumatic shock (refractory-only) <5% ped trauma needs surgical intervention Time to tertiary care support more important than time to trauma center Team availability Never accept a step-down in care for your patient
Alberta Air Ambulance Network ~9000 Air Ambulance flights in Alberta annually ~10% (~ ) provincial air tpts are Pediatric trips 70% provincial flight activity is in Central/ Northern Alberta Stollery PICU Air Ambulance trips ~500 advice/ transport calls to Stollery PICU intensivists/ year
Before the patient is transported… Does the airway need to be secured? General indications: altered LOC/ resp distress or decreased effort/ shock its more than just ABG/ 02 saturations Specific disease states (idiopathic vs. post-traumatic seizure) Patient age/ size Does the patient have co-morbidities? What is the trend? Do I need to intubate, or can it wait for the tertiary care team?
Assessment/ Management In the Transport Setting Ability (or not) to clinically assess the patient Ambient lighting: is the patient blue/ pink/ white/ grey? Noise: the stethoscope is useless ETT position, pneumothorax Motion artifact (BP cuff, 02 saturation monitor) What is the transport distance?
What is the mode of transport? It’s difficult to intubate in the cramped space of a helicopter or plane A ground ambulance can always pull off to the side of the road Assessment/ Management In the Transport Setting
Intubation Pre-Transport With oxygenation difficulties, lung compliance/ inflation is often compromised A cuffed ETT allows for consistent application of TV and PEEP ETT (cuffed) size is 0.5 size smaller than non- cuffed choice Oxygenation and ventilation can be provided with less toxic Fi02/ airway pressures
CXR post-intubation Pneumothorax: small becomes big at altitude/ with positive pressure ventilation ETT position post-intubation Capnography: intra-airway (still either high or low…) Brazelow tape: length not always = weight Clinical assessment is unreliable in small children Decompression of the stomach Gastric distention at altitude compromises ventilation, with or without ETT
Ventilating the Small Child Pre-transport Suction post-ETI Small airway and thick secretions Humidvent/ humidification Once the ETT is in, ventilate (sub-physiologic rate) 3 months:30 BPM 2 yrs. age:20 BPM 10 yrs. Age:12 BPM TV 5-7 cc/ kg or PiP<30/ move the chest PEEP 5 Titrate Fi02 to 02 sat>94% Baseline (CBG) and trend (EtC mm Hg)
Hemodynamic Stabilization Pre-Transport IV/ IO X 2 Not just trauma 2 nd IV allows for a back-up plan in the transport setting Shock states, repeated assessment every 10cc/ kg of fluid (NS): liver size, lung fields (creps) Titrate fluids not just to BP, but reversal of shock S/S (perfusion/ cap refill, HR,…) Tendency is to undertreat with fluids; most septic states require at least 60cc/ kg in first hr. of resusc’n
On-going fluid requirements due to vasodilation/ capillary leak If hypotension refractory to 60cc/ kg fluid, remember BS/ Cai/ inotropes Reassess, reassess, reassess; fluid/ drug requirements change over time Hemodynamic Stabilization Pre-Transport
Systolic Wave Variation/ Pulse Pressure Variability: check your pulse oximetry tracing (audio or visual) Has enough resuscitation fluid been given?
Mixing Inotropes: The Rule of 6’s vs. Pre-mixed bags of inotropes Run drugs dilute and titrate to BPs > 70 + (ageX2) Dopamine 6mg X (pt. weight) in 100cc D5W/ NS 1cc/ hr = 1 mcg/ kg/ min Start at 10mcg/ kg/ min (10cc/hr) Epinephrine 0.6mg X (pt. weight) in 100cc D5W/ NS 1cc/ hr = 0.1 mcg/ kg/ min Start at 0.1 mcg/ kg/ min
Once the ETT is in, keeping it in… Avoid benzodiazepines/ propofol due to vasodilatory effects Serial dosing of analgesic agents Fentanyl: 1-2 mcg/ kg q30-60 min Ketamine mg/ kg q1hr Morphine mg/ kg q1-2hr The patient with residual paralysis Titrate sedative/ analgesic dosing to jumps in HR/ BP Even these agents have vasodilator effects… Rocuronium 01.mg/ kg q30-60 min with patient movement
Temperature Management of the Pediatric Patient on Transport Small children lose significant heat (radiant/ evaporative/ conductive losses) Hypothermia increases SVR/ myocardial stress The importance of temperature (fever) control is disease specific Cardiac arrest: Avoid fever; don’t cool TBI: Avoid fever; don’t cool (harmful) The earlier fever is managed, the better for the patient (window of dose effect starts early)
ICU transport teams take longer to stabilize… Significant difference in stabilization times comparing kinds of transport teams ALS 0.44+/-0.15 hr ALS (peds)0.98+/-0.21 hr PICU1.24+/-0.34 hr McNabb, J Trauma, 1991
Transport stabilization times for neonatal and pediatric patients prior to interfacility transfer Whitfield, Children’s Emergency Transport Service, Denver,1993 Pediatric Stabilization Times All transports (n = 1106) 55 (10-419) Ventilated (n = 157) 88 (18-419) Ventilated with Inotropes (n = 13) 156 (55-419)
Summary of PICU tpt data Sick patients get sicker on transport Longer transports, sicker patients Sicker patients take longer to stabilize, and that is usually OK
Tex Kissoon’s Golden Rules of Transport Plan ahead Transports are palliative, not curative No form of transport is ideal for every patient Any hospital is a better hospital than an airplane or ambulance If it is possible for a sick person to become sicker, he probably will Big problems are simply small problems you have not anticipated Nothing lasts forever (eg. Air 02, battery, etc)
Keeping in touch Remember: This is your patient until you hand over to the transport team Reassess, reassess, reassess… Call PICU (through RAPID) if patient condition deteriorates; we are there to help No question is a stupid question