Recognize that Transport Is One of the Most Hazardous Intervals in the Perioperative Period and Prepare Accordingly

Recognize that Transport Is One of the Most Hazardous Intervals in the Perioperative Period and Prepare Accordingly

Mohammed Ojodu MD

Charles D. Boucek MD

Anesthesiology management includes the transport of patients (from the preanesthesia area or intensive care unit to the operating room, from the operating room to the intensive care unit or recovery room, and from many areas outside of the operating room where anesthesia is administered to the recovery room or the intensive care unit). During transportation, many avoidable pitfalls can arise.

Transportation of patients in the immediate perioperative period carries hazards due to both patient and equipment factors. Human factors and task loading also add to the risk. The anesthesia provider must manage a patient undergoing the transition from the anesthetized to the conscious state while also giving report, charting, removing stationary and applying portable monitors, and physically helping to move the patient. A transportation plan including the destination and route should be established and the patient, the anesthesia personnel, and all necessary equipment should be ready before transportation begins. A telephone call should confirm that the recovery destination is ready to receive the patient. The anticipated distance partially determines the equipment needed. All patients recovering from anesthesia should have supplemental oxygen. Monitoring devices, manual ventilators, intubation equipment, intravenous (IV) poles, portable infusion pumps, and medications may be needed for longer distances or critically ill patients. Useful medications include antiarrhythmics, agents to raise and lower blood pressure, sedation agents, and muscle relaxants. The added equipment and supplies complicate the move and may require more time or additional personnel.

During emergence from anesthesia, patients experience discomfort from both the surgical wound and airway devices. Nausea due to medications or movement, and gagging from pharyngeal stimulation, both can result in emesis and possible aspiration. Teeth clenching may limit the effectiveness of suctioning. Before the full return of situational awareness by the patient, attempts at self-extubation may occur. Self-induced corneal injury may occur when patients who have not yet regained full coordination attempt to rub their eyes. Patients may try to sit up or roll off the table. An
individual located at the patient’s head is at a mechanical disadvantage in trying to restrain a large patient. Available “safety straps” may also fail.

Residual effects of anesthetics can lead to hypoxia and hypotension. Opioids and muscle relaxants decrease respiratory reserve, whereas antihypertensives, intravenous and inhalational anesthetics decrease blood pressure. The transition from controlled to spontaneous ventilation may be accompanied by heightened airway reflexes. Functional residual capacity and respiratory drives are reduced. Release of dissolved anesthetic gasses, especially nitrous oxide, from the blood may displace oxygen from the alveoli and lead to diffusion hypoxemia. For patients being transported to the intensive care unit while still anesthetized, it is essential that ventilation is controlled and that perfusion is adequate.

One of the most effective ways to avoid hypoxemia is to provide supplemental oxygen. Oxygen delivery systems include nasal cannulae, face masks, manual ventilation bags with face mask, endotracheal tubes or laryngeal mask airways. It has been shown that healthy patients (ASA I and II patients) transported with oxygen after undergoing general anesthesia were less likely to desaturate during transport as compared to healthy patients who did not receive oxygen. For healthy extubated patients, oxygen provided via nasal cannula or face mask may be sufficient. For the transportation of seriously ill, intubated, or pediatric patients (pediatric patients are more prone to desaturate, as they have higher ratios of minute ventilation to functional residual capacity compared to adults), the ability to provide positive-pressure ventilation is important. Before transport begins, the adequacy of the supply of oxygen (usually provided in an e-cylinder) should be checked personally by the anesthesia provider because unexpected events may prolong the transport. (Editor’s note: Every single anesthesia provider with more than 2 minutes of experience can tell a story of asking the OR nurse to open the oxygen cylinder to 10 L/min, only to realize when the patient starts to desaturate going out the door that an empty tank has been put on the bed.)

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Recognize that Transport Is One of the Most Hazardous Intervals in the Perioperative Period and Prepare Accordingly
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