Regionalized intensive care for neonatology and pediatric care¹ focuses expensive, high-technology, labor-intensive therapies to a few regional centers. This model is based on the reduction of morbidity and mortality for trauma patients at designated trauma centers.^2,3 Because patients in need of specialized services often present to other hospitals, interfacility transport is an important complement to regionalized intensive care.⁴ Specialized pediatric transport services improve safety, decrease unplanned adverse events (especially airway events), and lower mortality.^4,5,6 This chapter reviews the general and pediatric considerations for the interfacility transport of critically ill neonates and children.

Caring for critically ill children is best accomplished with at least two patient care providers on each team in addition to the driver or pilot. One of the patient care members should be a registered nurse with a minimum of 5 years of experience, typically at least 3 years of neonatal or pediatric critical care or ED training.⁴ Additional member(s) may include a respiratory therapist, physician, or paramedic. The condition of the child and local resources determine the exact composition of the specialized transport team.

Transporting critically ill patients adds to the risks of the illness or injury because of the hazards associated with the transport environment, particularly for neonates and children.⁷ The features of transport that distinguish the transport environment from the ED setting and the effects of these features on patients and caretakers are outlined in Table 107-1.

PRECAUTIONS

Suggested guidelines to minimize the impact of the limitations inherent in a transport environment are

1. 
   

   Prepare the transport vehicle. Transport vehicles should be prepared to meet the special needs of children (e.g., accessory lighting, controlled thermal environment) and should be stocked with the necessary equipment. A list of the minimum necessary equipment for ambulances, which can serve as a guide for EMS agencies, has been published by the Emergency Medical Services for Children program.¹⁰

   
   
2. 
   

   Stabilize the patient 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. Time spent undertaking goal-directed intensive care interventions early in the course of the patient illness at the referring hospital does not worsen patient outcomes.¹¹

   
   
3. 
   

   Monitor as many physiologic parameters as possible electronically. Because physical examination is difficult during transport, and because children often are transported during dynamic changes in their physiologic condition, electronic monitoring is essential. Important monitoring equipment commonly used during transport includes cardiorespiratory monitor (selected based on its size, weight, battery life, and resistance to motion artifact); continuous pulse oximetry with a plethysmographic waveform to assist in identifying motion artifact; temperature monitor (of infants and incubator air temperature); carbon dioxide monitor using continuous inline infrared analysis (or transcutaneous carbon dioxide monitoring or arterial blood analysis), which can aid in early identification of unplanned extubation¹²; invasive or noninvasive blood pressure monitoring; and portable blood gas analyzer.

   
   
4. 
   

   Anticipate deterioration. Preparation of the patient should include not only care for the identified problems but also anticipation of problems that may arise during transport. The application of this principle may lead to performance of procedures or therapies before transport such as gastric decompression, placement of a chest tube for pneumothorax, or transfusion.

DECISION TO TRANSPORT

Children require transfer to a regional center if the current or anticipated medical care needs of the patient exceed the resources of the local hospital. Arranging transfer to the regional center can occur simultaneously with assessment, resuscitation, and stabilization at the local hospital. Discussion with the receiving hospital and specialists can aid in decisions regarding the mode of transport and composition of the transport team.

ASSESSMENT

Proper assessment is the cornerstone of neonatal and pediatric critical care, as management cannot begin until the critical patient is correctly identified. An important tool in pediatric assessment is the Pediatric Assessment Triangle (Figure 107-1). Each face of the triangle represents a critical feature in neonatal and pediatric assessment: Appearance, Work of Breathing, and Circulation. This method can be applied quickly to reliably and accurately assess a potentially critically ill patient and determine the need for life-saving interventions.

BASIC ASSESSMENT

Stabilization is the responsibility of the referring hospital personnel, to the limits of their abilities and resources. Because dealing with a sick neonate is an infrequent occurrence for people working outside of neonatal intensive care units, the Sugar/Safe care, Temperature, Airway, Blood pressure, Lab evaluation, Emotional support (STABLE) mnemonic was created by the developers of the S.T.A.B.L.E.^® course (http://www.stableprogram.org) to aid recall of the steps for managing infants prior to transport.¹³ The principles of STABLE include maintaining blood glucose at 50 milligrams/dL for transport; sustaining a neutral thermal environment with a core temperature range for a neonate of 36.5°C to 37.5°C (97.7°F to 99.5°F); assuring airway patency and respiratory support necessary for optimal ventilation and oxygenation; maintaining adequate blood pressure to provide oxygen delivery to the tissues (normal blood pressure for preterm infants is 45 to 60/25 to 35 mm Hg); laboratory evaluation directed by the underlying condition; and emotional support for the family in crisis.

AIRWAY MANAGEMENT

Intubation and mechanical ventilation are performed to (1) protect the airway from obstruction, (2) ensure adequate ventilation, or (3) provide adequate oxygenation. While this principle applies to both inpatients and those being prepared for transport, the threshold for intervention is lowered for patients requiring transport.¹⁴ For example, an infant with an elevated partial pressure of arterial carbon dioxide level might be observed without ventilatory support in the inpatient setting but may need to be intubated and ventilated in preparation for transport. In addition, children without respiratory failure but in whom deterioration is anticipated should be intubated in preparation for transport. This more aggressive approach to airway management is justified because the ability to identify respiratory failure and to intubate is impaired during transport.

Principles of infant and pediatric airway management including appropriate airway equipment and sizes are reviewed in chapter 111, “Intubation and Ventilation in Infants and Children.”

Some airway problems specific to transport are worthy of mention. Even if the child is already intubated at the transferring institution, or if intubated by the transport team confirm or reconfirm tube placement by several methods: direct visualization, auscultation, end-tidal carbon dioxide detection, or chest radiograph for positioning.¹⁵ Make sure the endotracheal tube is well secured, and stabilize the tube by hand when moving the child to make sure movement doesn’t dislodge the tube from the trachea into the esophagus. Right mainstem intubation is common in neonates. Prolonged right mainstem intubation increases the likelihood of pneumothorax and is particularly hazardous in premature infants, many of whom will later receive surfactant through the endotracheal tube. Before departure, and soon after the initiation of mechanical ventilation, obtain an arterial blood gas analysis to ensure appropriate oxygenation and ventilation.

Ventilators for transport should accommodate the needs of all pediatric age groups. Neonates are most often ventilated with time-cycled, pressure-limited ventilators using intermittent mandatory ventilation. Older infants and children typically require volume-assisted ventilation using synchronized intermittent mandatory ventilation. Causes of acute decompensation in the mechanically ventilated patient can be remembered using the DOPE mnemonic: (1) dislodgement or obstruction of the endotracheal tube; (2) faulty oxygen source; (3) pneumothorax; and (4) equipment failure.

Initial Ventilator Settings

Neonates are most often ventilated with time-cycled, pressure-limited ventilators using intermittent mandatory ventilation. The goals of mechanical ventilation are to maintain adequate tissue oxygenation while minimizing pressure-induced trauma to the lungs. This is best achieved utilizing a strategy of effective lung recruitment with positive end-expiratory pressure combined with permissive hypercapnia.¹⁶

Preset peak inspiratory pressure, a positive end-expiratory pressure, and an inspiratory time determine the volume of each breath. Suggested initial peak inspiratory pressure for term neonates is 20 to 25 cm of water depending on the severity of respiratory disease, while positive end-expiratory pressure is usually set at 5 cm of water, with an inspiratory time of 0.3 to 0.35 seconds and a rate of 20 to 40 breaths per minute.

Older infants and children typically require volume-assisted ventilations using synchronized intermittent mandatory ventilation, with a volume of 8 to 10 mL/kg, positive end-expiratory pressure of 5 cm of water, pressure support of 10 cm of water, fraction of inspired oxygen >60%, and variable rate depending on normal rate for age and underlying disease process. Obtain an arterial blood gas after initiation of mechanical ventilation to guide future changes. Increases in oxygenation can be achieved by increasing positive end-expiratory pressure and fraction of inspired oxygen, whereas increases in ventilation can be achieved by increasing rate and pressure support.

Ventilator Troubleshooting

Causes of acute decompensation in the mechanically ventilated patient can be remembered using the DOPE mnemonic, discussed earlier: (1) dislodgement or obstruction of the endotracheal tube; (2) faulty oxygen source; (3) pneumothorax; and (4) equipment failure.

The Difficult Airway