Transcript Transport of Critically ill patients - RT`s Role

TRANSPORT OF
CRITICALLY ILL PATIENTS
DR.T. GOPINATHAN MD.,IDCCM.,EDIC
Consultant Intensivist
Department of Critical Care Medicine,KMCH
HISTORY
Dominique Jean Larrey ( 8 July 1766 – 25 July 1842 )
French surgeon in Napolean’s army and an important innovator in battlefield medicine
RESCARE 2015
ICU UPDATE 2015
INTRODUCTION
• Need for additional care, either technology and/or specialists, not available
at the patient's current location
• Involves some degree of risk to the patient and sometimes to the
accompanying personnel. ( 6 -71%, life threatening 8% IHT)
• These risks can be minimized and outcomes improved with careful
planning, the use of appropriately qualified personnel, and selection and
availability of appropriate equipment.
RESCARE 2015
ICU UPDATE 2015
TYPES OF TRANSFER
• Primary transfer – home/street to ER/ICU
• Secondary transfer – Intra / Inter hospital
• Emergency or elective
RESCARE 2015
ICU UPDATE 2015
TYPES OF TRANSFER
• Basic requirements are similar for inter hospital and intra
hospital transport.
• However, inter hospital transport requires more careful
planning, a greater variety of drugs, a higher battery backup,
well equipped vehicle, essential gases for life support and an
experienced medical crew.
RESCARE 2015
ICU UPDATE 2015
ADVERSE EVENTS
RESCARE 2015
ICU UPDATE 2015
RELATED TO EQUIPMENT
•
Monitor Power Failure
•
Ventilator disconnect/failure
•
Depleted oxygen supply
•
Oxygen Probe Failure
•
Tubing tangles
•
ECG lead disconnection
RESCARE 2015
ICU UPDATE 2015
RELATED TO STAFF
• Gaps in monitoring
•
Loss of chest tube
• Missed treatment/medications
•
Loss of invasive access
•
Under/Over Resuscitation
•
Loss of ICP monitor
• Unintended Airway Extubation
• Under ventilation
• Over ventilation
RESCARE 2015
ICU UPDATE 2015
RELATED TO PATIENT
• Airway
-
Aspiration
• Breathing
-
Derecruitment
Desaturation
Increased oxygen consumption
• Circulation
-
Arrhythmia
Hypothermia
Hyper/hypotension
• Neurological -
RESCARE 2015
Agitation/Pain
ICU UPDATE 2015
ADVERSE EVENTS
• Minor AEs - physiological decline of more than 20%
problem due to equipment
• Major AEs - which put the patient's life at risk and
require urgent therapeutic intervention.
RESCARE 2015
ICU UPDATE 2015
CIRCUMSTANCES
RESCARE 2015
ICU UPDATE 2015
CONDUCT OF TRANSFER
•
The ideal way to imagine transport of a critically ill
patient is to imagine it as a “mobile, but seamless
continuation of the ICU environment”.
RESCARE 2015
ICU UPDATE 2015
CONDUCT OF TRANSFER
Remember acronym…..
Assessment
Control
Communication
Evaluation
Prepare and package
Transport
RESCARE 2015
ICU UPDATE 2015
ASSESSMENT
• Initial assessment of the patient and situation as a
whole
• Indications - benefits must outweigh risks
• Stabilize before transport
• Anticipation of problem likely encountered en route
• Degree of urgency to transfer
RESCARE 2015
ICU UPDATE 2015
ASSESSMENT
RESCARE 2015
ICU UPDATE 2015
CONTRAINDICATIONS
• Inability to provide adequate oxygenation and ventilation during
transport either by manual ventilation, portable ventilator, or standard
intensive care unit ventilator
• Inability to maintain acceptable hemodynamic performance during
transport
• Inability to adequately monitor patient cardiopulmonary status during
transport
• Inability to maintain airway control during transport
• Transport should not be undertaken unless all the necessary members
of the transport team are present
RESCARE 2015
ICU UPDATE 2015
CONTROL AND COMMUNICATE
• Communication - excellent communication within team and
receiving end
• Continuous assessment of effectiveness of resuscitation and
stabilization process
• When an alternate team at a receiving location will assume
responsibility for the patient after arrival, continuity of
patient care will be ensured by physician-to-physician and
nurse-to-nurse communication to review patient condition
and the treatment plan.
RESCARE 2015
ICU UPDATE 2015
TRANSPORT
RESCARE 2015
ICU UPDATE 2015
PERSONNEL
• It is recommended that a minimum of two people , in addition to the vehicle
operator, accompany a critically ill pt.
• It is strongly recommended that a physician with training in airway
management and ACLS, and critical care training or equivalent, accompany
unstable patients.
• The team must be proficient in operation and troubleshooting all of the
equipment
• The transferring personnel should be familiar with the patient’s history,
condition and special requirements to allow appropriate planning and
anticipation of problems unique to the patient.
RESCARE 2015
ICU UPDATE 2015
EQUIPEMENT GENERAL PRINCIPLES
• Choose equipment that you are familiar with and check every piece
to make sure it works.
• Never place equipment on top the patient.
• Equipment often comes in different sizes - have an appropriate
selection for your patient.
• Ensure adequate power (battery pack) backup and check that they
are fully charged, but plug the equipment back in at destination
• Check that gas cylinders are full and function (estimate > 30 min
more than needs).
• Check that you have enough spare IV fluids.
RESCARE 2015
ICU UPDATE 2015
EQUIPEMENT GENERAL PRINCIPLES
• A cellular phone and a key to call the elevator are useful for emergencies.
• Antibiotics should be brought along to keep the patient on schedule with
antibiotics
• Transport protocol should define who is responsible for checking and how
often.
• All procedures for the proper setup, maintenance, and use of all equipment for
transport must be strictly followed.
• Some patients may not tolerate movement and/or changes in ventilatory
support. A trial of body movement, manual ventilation, or application of
transport ventilator in the ICU is warranted to ensure patient tolerance
RESCARE 2015
ICU UPDATE 2015
DRUGS
• Cardiac arrest
• Intubation
• Hypotension and hypertension
• Agitation and pain
• Cardiac dysrhythmia
• Anaphylaxis
• Bronchospasm
• Hypoglycaemia and hyperglycaemia
• Seizures
RESCARE 2015
ICU UPDATE 2015
DRUGS
In specific circumstances it may be necessary to be able to
treat the following during transport: •
Raised ICP
•
Uterine atony
•
Adrenal dysfunction
•
Narcotic depression
RESCARE 2015
ICU UPDATE 2015
PREPARE AND PACKAGE
• Verify physician's order.
• Gather and assemble all equipment. Maintain electrical
power to all monitors prior to departure to ensure the
maximum charge of the batteries.
• Label, level, and zero all pressure transducers.
• Secure all pressure monitoring lines to avoid inadvertent
disconnection and decannulation.
• Set appropriate alarm limits for all monitored parameters.
• Stop nutrition
RESCARE 2015
ICU UPDATE 2015
PREPARE AND PACKAGE
• All bags emptied before departure
• Lines, cables and drainage tubes (Heimlich chest tube valve, abdomen,
bladder) unclamped, functional, secure, untangled and transportable
• Limit the number of infusion pumps as much as possible
• Aspirate the patient before departure and check the cuff pressure of
endotracheal tube
• Consider appropriate physical restraints for the patient if indicated.
• Do not forget to take patient notes and images. If patient consent is required
– do you have it?
RESCARE 2015
ICU UPDATE 2015
PREPARE AND PACKAGE
• Head raised if possible (to prevent intracranial hypertension and ventilatorassociated pneumonia)
• Prepare medication (emergency, sedation, analgesia, paralysing agents), fluid
loading solutions
• Route for venous access isolated and secured (quick injection, administration
of vasopressors)
• Always reassess the patient immediately prior to leaving, with all transport
equipment attached and functioning – following an A – airway, B – breathing,
C – circulation, D – drugs, and E – equipment algorithm will ensure you not
missing anything.
RESCARE 2015
ICU UPDATE 2015
CHECKLIST FOR PREPARATION
RESCARE 2015
ICU UPDATE 2015
MONITORING
•
Same level of basic physiologic monitoring during transport as received in
the ICU.
•
Continuous ECG ,pulse oximetry and periodic measurement of blood
pressure, pulse rate, and respiratory rate.
•
In addition, selected patients may benefit from capnography, continuous
intra-arterial blood pressure, pulmonary artery pressure, or intracranial
pressure monitoring.
•
Alarms should be visible as well as audible in view of extraneous noise levels
RESCARE 2015
ICU UPDATE 2015
POST PROCEDURE
• Upon returning to the unit, place the patient on the appropriate bedside
monitoring and respiratory equipment.
• Re-level and re-zero all pressure transducers.
• Check and reset all necessary alarm parameters and ensure patient
comfort.
• Remove all transport equipment from the patient's room, disinfect as
appropriate, and store monitors with connection to AC power for
recharging of the batteries.
RESCARE 2015
ICU UPDATE 2015
DOCUMENTATION
•
Document the ventilator or oxygen settings prior to departing and upon
returning to the unit.
•
Document any cardiopulmonary or hemodynamic changes that may
have occurred during the transport
•
Include the occurrence of adverse reactions and interventions that were
made.
•
Documentation serves to remind the team to systematically check
monitoring and patient status, helps to identify trends in the patient’s
condition earlier, and allows quality assurance activities. The medicolegal implications of documentation are obvious.
RESCARE 2015
ICU UPDATE 2015
CHECK LIST
RESCARE 2015
ICU UPDATE 2015
CHECK LIST
RESCARE 2015
ICU UPDATE 2015
CONCLUSION
•
Adverse effects during and after transport of critically ill patients are
frequent.
•
Although a few patient-related risk factors can be identified, the rate
of equipment-related adverse events may be as high as one-third of
all transports.
•
Thus, particular attention has to be focused on the personnel,
equipment and monitoring in use.
RESCARE 2015
ICU UPDATE 2015
CONCLUSION
• To further reduce the rate of inadvertent mishaps from
transports, alternative diagnostic modalities or techniques,
and performing surgical procedures in the ICU should be
considered whenever possible.
RESCARE 2015
ICU UPDATE 2015
…….. For your patience and opportunity
RESCARE 2015
ICU UPDATE 2015
Thank you!
RESCARE 2015
ICU UPDATE 2015