Page 107 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 11: Transportation of the Critically Ill Patient 75

Patient Documentation: As well as documentation to be completed
during the transfer, copies of notes, referral letters, and digital or film
imaging should accompany the patient.
Transfer Documentation: Recording of observations of vital signs that
would usually be recorded on the intensive care unit should be contin-
ued during transfers, at a frequency guided by the degree of stability
of the patient.
Particular note should be made of observations that are likely to
deteriorate during the transfer such as hemodynamic stability and pain
scores. As well as the usual physiological data collection, transfer tools
51
have been developed integrating descriptions of monitoring and special
equipment, checklists, and event descriptions. Such tools may not only
improve patient safety but also allow efficient follow-up and surveillance
of transport-related incidents. 62
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FIGURE 11-2. Long-range transfer of a military trauma patient by a specialist transfer team. SPECIAL CIRCUMSTANCES/CLINICAL CONDITIONS

ECMO: A number of specialist regional centers provide extracorporeal
and the presence of positive end expiratory pressure, no particular membrane oxygenation (ECMO) and related therapies such as pumpless
patient group has a significantly increased risk of deterioration or mis- extracorporeal lung assist and extracorporeal life support (ECLS) for
hap during the transfer, thus meticulous monitoring and care must be patients with refractory lung or heart failure. There may be a require-
48
taken for all patients. A number of observational studies have concluded ment to initiate one of these therapies in a critically ill patient outside
that both manual and mechanical ventilation can result in hyperven- of these units, with subsequent transfer to the specialist center. There
tilation, thus capnography and arterial blood gas analysis should be are considerable logistic and practical considerations involved in such
utilized during long-distance transfers. 48,59 transfers, and therefore, their use is generally restricted to specialist
The team should be aware of the location of the receiving unit, or met teams familiar with the equipment. Two units have described their expe-
by a member of the receiving team on arrival at the hospital. Relatives riences of transferring these patients. 63,64 Despite mechanical stresses
should be updated on the progress of the transfer but should not rou- such as vibration during helicopter takeoff and landing, neither institu-
tinely accompany the patient. 21 tion reported equipment malfunction or dislodgement of lines, though
two cases of compartment syndrome due to arterial occlusion were
Physiological Effects of Transfer: A cross-sectional analysis of intrahos- noted. The reduction in ambient pressure and oxygen availability reduce
pital transfers reported to the Australian Incident Monitoring Study the performance of membrane oxygenators, resulting in an oxygen
in Intensive Care (AIMS_ICU) concluded that serious adverse events desaturation of 3% to 4% at a cabin altitude of 5000 ft. 63
occurred in 31% of the 176 reports submitted. Patients commonly
40
undergo alterations in blood pressure, respiratory parameters, and Head Injuries/Intracerebral Bleeds: While patients with mild traumatic
65
body temperature. 60,61 Unfortunately those patients at risk of physi- brain injury can be monitored safely in most nonspecialist units,
ological deterioration cannot be reliably predicted prior to transfer. severely head injured patients often require specialist neurosurgical
intervention and monitoring to reduce the impact of secondary brain
All Transfers injury. 66,67 Transfer of the head injured patient, whether intrahospital
• Gravitational forces: Ideally the long axis of the patient should be or interhospital, has been associated with deleterious effects such as
placed perpendicular to the direction of travel to minimize the effects reduced brain tissue oxygenation, resulting in increased secondary
of acceleration and deceleration. In practice, safety restraints in most brain injury. 58,68 Despite many of these transfers being time critical, such
vehicles will not allow this. Those with hypovolemia or a reduced patients must be carefully resuscitated prior to departure.
capacity to increase cardiac output, such as cardiac failure, are most at
risk of complications secondary to such forces. To attempt to reduce Major Trauma/Spinal/Burns: Centralization of trauma and burns
this risk, the circulating volume should be near normal prior to services has resulted in the concentration of expertise at specialist
departure. The patient should be placed head up to minimize the trauma units. The hazards of interhospital transfer appear to be offset
8,27
effect of alterations in gravitational forces on intracerebral pressure. by the improved care received at such units, even for those patients
26
Unnecessary high-speed transfers should be avoided. 8 requiring air transportation over long distances. McGinn et al
advocate the use of a specialist retrieval team, based at the receiving
• Motion sickness: This can cause nausea and vomiting in both patients hospital, as their experience of this system did not demonstrate delays
and staff. in transfer when compared with transfers undertaken by nonspecialist
• Vibration: Related to changes in floor or ground surface or transmit- teams from the referring unit. This service would incur extra costs to
ted vehicle engine vibration. It may increase pain and anxiety or the system but outcomes may be improved by the increased expertise
45
increase mobility of respiratory secretions, increasing the require- of the transfer team. Both European and US studies have established
15
ments for endotracheal suction. that severely injured patients who were transferred from nonspecialist
• Changes in ambient temperature: Most commonly the patient is hospitals to specialist trauma centers have better outcomes than those
exposed to cold, especially while being transferred to and from vehicles. who remained in nonspecialist units. 66,69 Primary transfer by air in the
United Kingdom has been shown to benefit only the most seriously
Transfers by Air injured or burned patients, most likely due to the smaller distances
• Gaseous expansion by a factor of 1.35 when ascending from sea level to a involved when compared to larger countries. 70,71 Movement of patients
cabin altitude of 8000 ft, resulting in gas trapping within body compart- with spinal injuries can potentially result in deleterious neurological
ments, pain, nausea, and barotrauma or even decompression sickness. effects, and no method of transport has been shown to be superior
• Reduced humidity—drying of secretions, dry mucous membranes to any other in this patient group. Ideally, these patients should be
transferred directly to a spinal unit, preventing the need for secondary
• Patient fear or anxiety transfer, though in practice accurate assessment of spinal injuries at the
• Turbulence scene of the incident can be difficult. Consideration should be taken
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