Regionalized intensive care is a concept that has gained wide
acceptance in neonatology and pediatric care.1 This
concept mandates that expensive, high-technology, labor-intensive
therapies be limited to a few regional centers. Because patients
in need of these services may initially present to other hospitals,
interfacility transport has developed as a complement to regionalized
intensive care.2 The referring hospital or, more commonly,
the regional center, may assume the responsibility for transport
of a patient to a regional center. Because community EMS systems often
are not equipped to transport critically ill children, the interfacility transport
of pediatric patients frequently is conducted by specialized transport
services.2 Under these circumstances, the referring
hospital and its medical care staff have important responsibilities
related to transport; ED personnel often assume these responsibilities
because the ED is the site of initial care.
Moving critically ill patients between hospitals invariably adds
to the risks of the illness or injury because of the hazards associated
with the transport environment, particularly during the transport
of neonatal and pediatric patients.3 An understanding
of the transport environment is important for individuals who participate
in the preparation of a patient for transport, as well as for those
who conduct the transport. The features of transport that distinguish
this environment from the inpatient setting and the effects of these
features on patients and caretakers are outlined in Table 4-1.
4-1 Features of Transport versus Inpatient Setting and Effects
| Save Table
4-1 Features of Transport versus Inpatient Setting and Effects
|Noise||Reach levels 90–110 dB4,5||Ear plugs|
|Arterial desaturation in infants||Monitors to allow visual cues|
|Inability to auscultate|
|Vibration||Autonomic/central nervous system motion-induced illness (sopite, nausea syndromes)||Accommodation|
|Equipment motion artifact||Alternative monitoring|
|Inadequate lighting||Poor visual cues||Compartmental lighting 400 lux|
|Complications with procedures||Task lighting 1000–1500 lux|
|Temperature||Gradient-dependent heat loss by convection
and radiation||Limiting time in transport|
|Thermal regulation of vehicles and surfaces|
|Double-walled isolettes for infants|
|Humidity||Nonhumidification of respiratory gases causes dehydration,
secretion tenacity||Humidify gases for long (>2 h) transports|
|Altitude||Decreased Po2||Pressurize aircraft|
|Expansion of gases in closed spaces||Ventilate closed-space gas to atmosphere|
|Significant for nonpressurized aircraft above 5000 ft (1500
m)||Orogastric tube, decompress pneumothorax)|
|Confined space||Limits crew, workspace, equipment||Efficient use of patient care space in vehicle|
|Typical sizes: 47 sq. ft (ambulance)||Experience|
|22–36 sq. ft (helicopter)|
|150 sq. ft (neonatal intensive care unit patient space)|
|Limited support||Hospital-based radiographic and laboratory services unavailable||Portable blood analyzer (i-STAT)|
|No onsite additional clinical expertise||Thoughtful planning of radiographic needs|
|Consultants via telecommunications|
|Equipment failure||Exhaustion of respiratory gases, supplies,
|Thorough supply checks|
|Monitor deterioration secondary to vibration||Routine accelerated maintenance schedule|
Suggested guidelines to minimize the impact of the handicaps
inherent in a transport environment are:
1. Prepare the transport vehicle. If
repeated transport of pediatric patients is anticipated, one or
more vehicles should be prepared to meet the special needs of this
patient population (e.g., accessory lighting, controlled thermal
2. Stabilize the patient carefully before transport. Unless
the immediate needs of the patient can only be met in the receiving
hospital (e.g., emergent surgery), ample time should be devoted
to stabilizing the patient in the referring hospital.
3. Monitor as many physiologic parameters as possible electronically. Because
physical examination is difficult during transport, and because pediatric
patients often are transported during dynamic changes in their physiologic
condition, electronic monitoring is essential. The following monitors
are commonly used during transport:
a. Heart rate and respiratory monitor. All
transported patients should be monitored with impedance ECG and
respiratory monitoring. The selection of a monitor should be based
on its size, weight, battery life, and resistance to motion artifact.
The monitor should include a screen with a graphic display of ECG
and respiratory tracings. Ideally, the monitor should display pressure
waveforms and digital readings of systolic, diastolic, and mean
blood pressures from transduced intravascular catheters. It is not
essential that the monitoring system include the capability of electrical
cardioversion or pacing; the need for such a device in the care
of pediatric patients is extremely rare. These devices have become
more streamlined, and this capability should be available during
the transport of patients with known arrhythmias or patients at
risk for such problems (e.g., tricyclic antidepressant poisoning
or complex heart disease).
b. Pulse oximetry. Continuous pulse oximetry is
essential in patients with cardiorespiratory illness. Devices that
display a plethysmographic waveform are ideal because they assist
in identifying motion artifact.
c. Body temperature monitor. Frequent (or continuous)
temperature monitoring of the infant and the incubator air temperature
is helpful in neonates and small infants because of their predisposition
d. Carbon dioxide (co2) monitor. Continuous
estimation of Paco2 is helpful in patients
with respiratory failure. Capnography, using continuous inline infrared
analysis to measure end-tidal co2, has become popular
as an alternative to transcutaneous co2 monitoring
or arterial blood analysis. Colorimetric co2 detectors
to confirm endotracheal tube placement in the airway are readily
available and are especially helpful during transport when there
is emergent concern of inadvertent extubation.
e. Blood pressure monitor. Noninvasive blood
pressure monitoring is advisable in children without indwelling
arterial catheters. The cuff should cycle frequently enough to provide
meaningful information about changes in hemodynamics. Arterial pressure
can be monitored directly in patients with indwelling arterial catheters.
Direct monitoring is preferable because it is more accurate and
provides an alarm system in the event that arterial pressure suddenly
drops. Periodic noninvasive blood pressure monitoring is also useful
in patients with direct monitoring to differentiate abnormal findings from
f. Portable blood analyzer. Small, battery-powered
devices are available for the performance of blood gas analysis
and measurement of selected blood chemistries (e.g., electrolytes,
hematocrit, and blood ...
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