CASE 30
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Incident
A 49-year-old man has been admitted to a general hospital ICU without cardiothoracic surgical expertise 2800 km (1740 miles) away. He has a past history of bicuspid aortic valve, subacute bacterial endocarditis and aortic valve replacement. He has now presented with cardiogenic shock, atrial fibrillation, respiratory failure and renal and hepatic failure secondary to acute mitral regurgitation. Acute rupture of the mitral chordae tendinae and fenestration of the anterior mitral leaflet were diagnosed via transoesophageal echocardiography in the ICU.
He is intubated and ventilated. An intra aortic balloon pump (IABP) has been inserted. Continuous renal replacement therapy (CRRT) has been instituted for oliguria and metabolic control.
Current clinical information is as follows:
Circulation
• P 115 atrial fibrillation.
• BP 105/65 mmHg.
• CVP 31 mmHg.
• PAP 82/33 mmHg.
• Support:
• IABP – 1:1 and full augmentation.
• Dobutamine at 15 μg/kg/min.
• Milrinone at 0.7 μg/kg/min.
In the past 12 hours, his haemodynamic status and hepatic function has deteriorated despite increasing support. He has been referred for urgent mitral valve replacement (MVR) in a tertiary referral centre at your location.
Relevant information
▪ Aircraft: Learjet 35A – two-stretcher capacity
▪ Local resources: Modern fully equipped and staffed ICU. Road ambulance
▪ Retrieval options: Cardiothoracic specialist centre 2800 km (1740 miles) from current location
▪ Other: A second patient with stable coronary artery disease following acute myocardial infarction 5 days ago also requires transfer for semi-elective coronary artery bypass graft
Questions
30.1 A colleague who has overheard the referral informs you the patient should not be retrieved as:
• he is unlikely to survive the transport and
• the level of care currently available in the referral ICU cannot be matched in transit
How will you respond?
30.2 The retrieval is planned to go ahead. How will you prepare and manage the IABP in transit?
30.3 The aircraft has dual-stretcher capacity. Are you happy to take the second patient with you as well?
Discussion
30.1 Your colleague may be correct. However, neither of his concerns excludes potential safe retrieval of this patient for definitive intervention. At some point in the risk–benefit assessment required for all patient movements, the benefits of further diagnostic testing or availability of specialised care at the destination facility will outweigh the risks inherent in patient transfer. This is arguably one such case. However, this is a complex case and a senior member of the retrieval service should be notified.
Two firmly held philosophies of retrieval care are challenged by this scenario. The first relates to the requirement to achieve the maximum level of clinical stability prior to any transfer. The second relates to the requirement to at least match, if not increase, the level of care available to the patient in transit when compared to the point of referral.
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