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CLINICAL GUIDE
Transport of critically ill patients is an established malfunction. Further, a reduced availability of personnel,
practice in today's field of emergency medicine. Many equipment and monitoring away from ICU may be
potential problems may be avoided by optimization of the detrimental The first indication that transport with in
patient's condition before transport. Despite all efforts hospital is a dangerous undertaking was provided in early
taken to minimize any complication arising during 1970's when arrhythmias were encountered in upto 84%
transport, we still have a long way to go and a Herculean of transport of patients with cardiac disease, which
task ahead of us. required emergency therapy in 44% of cases (1).
Introduction Hypotension and arrhythmias occur predominantly in
Safest place for the critically ill patient is in the intensive mechanically ventilated patients (2, 3). Events being
care unit (ICU), connected to a sophisticated ventilator closely related to periods of hypoventilation or
with all infusion pumps running smoothly, monitoring hyperventilation with changes of pCO2 of up to 27 mm
equipment installed and with a nurse present to care for Hg. Respiratory complications include changes in
the patient. The patient is more or less in a controlled respiratory rate, fall in PaO2 (4). In patients with head
environment There may be situations when the patient injury, adverse effects include hypotension, hypoxia and
has to leave these secure surroundings to be transported increased intracranial pressure.
to the radiology department, operating room or some other Equipment related complications include ECG lead
hospital. This transport may create an increased risk for disconnection, monitor power failure, disconnection of
mishaps and adverse effects by disconnecting such intravenous or intra arterial lines or from the ventilator
critically ill patients from equipment, shifting them to itself (4). Failure of suction apparatus to work during
another stretcher and reducing the person and equipment transport or accidental extubation would lead to disastrous
around. consequences. To prevent all such complications, various
This article provides the reader with the information guidelines for transport of critically ill patients were
about various adverse effects during transport and reported by representatives from several major critical
guidelines to perform safe transport of the patient; care societies. These introduce the minimum
covering the personnel accompanying the patient, requirements, which should be available during the
equipment for monitoring the patient and treating transport of any patient in serious condition.
complications if any. General Principles
Adverse effects Definition:- Critically ill patients are those that by
Transport may affect a variety of organ systems, may dysfunction or failure of one or more organs/system
be related to movement of the patient e.g. dislocation of depend on survival from advanced instruments of
installations, drips etc. or caused by equipment monitoring and therapy (5).
From the Postgraduate Department of Anaesthesiology & Intensive Care, Govt. Medical College, Jammu (J&K).
Correspondence to : Dr. Satyadev Gupta, Prof. & Head, PG. Deptt. of Anaesthesiology & Intensive Care, Govt. Medical College, Jammu.
Following steps are taken 2. Professionals with the Patient:- Two professionals
1. Decision:- The decision of transporting a patient in (doctors/nurses) should accompany the patient in
serious condition is a medical action. Therefore, the serious condition at least
responsibility is ascribed to the doctor who is attending (a) One of the professionals should be the nurse in
the patient but also from the chief of the team and the charge of the patient, with experience in CPR or
service direction. specially trained in transport of patients in serious
2. Planning:- The planning of the action is affected by conditions.
the medical and nurse team of the service or unit and (b) In accordance with the serious condition and
considers the following problems:- instability of the patient, second professional can
(i) Choice and contact with the receptor service, be a doctor or nurse.
evaluating the distance and time delay. (c) A doctor should attend the patients who present
(ii) Choice of mode of transport- air or road. If the physiological instability and eventually will need
distance is greater than 150 km, air transport is an urgent action.
preferred. 3. Equipment to support the patient
(iii) Selection of accurate monitoring methods and (a) Transport Monitor
devices. (b) Blood Pressure reader
(iv) Prediction of possible complications. (c) Endotracheal intubation kit and manual
(v) Selection of general and specific therapy resuscitator
instruments. (d) Oxygen source with a predictable capacity for
(vi) Choice of transport team (according to the the whole period of transport, with additional
availability and the characteristics of the patient). reserve for 30 minutes.
3. Implementing:- The implementing of the transport (e) Portable ventilator, with availability to offer
is incharge of the selected transport team and its technical volume/minute, pressure FiO2 of 100% and PEEP
and legal responsibility finishes only when patient is with disconnection alarm and high airway
delivered to medical team of destinations service or on pressure alarm.
arrival to original service (when transport is done for (f) Suction apparatus with suction catheters.
fulfilling of any diagnostic/therapeutic procedure). (g) Drugs for resuscitation, namely adrenaline,
Intra-hospital transport of critically ill patient lignocaine, atropine and sodium-bicarbonate.
The transport is in the hospital of the patient should (h) Intravenous fluids and infusion of drugs ruled by
follow these rules:- syringes or infusing pumps with battery.
1. Coordination before the transport (i) Additional medications to be administered
(a) Previous information that the area where the according to medical prescription.
patient is meant to be moved is ready to receive 4. Monitoring During the Transport :-The levels of
service him/her and to make the exam or planned monitoring have been divided according to following (6):-
therapy. Level 1 - Compulsory
(b) Doctor in charge should accompany the patient Level 2 - Highly recommended
and communication between doctor to doctor and Level 3 - Ideal
nurse to nurse should be established, regarding Continuous Monitoring with Periodical record
the medical situation of the patient and the therapy * ECG (Level 1)
before and after removal. * Pulse Oximetry (Level 1)
(c) Write in the medical record the events occurred Intermittent Monitoring and record
during the transport and the evaluation of the * Blood Pressure (Level 1)
condition of the patient. * Heart rate (Level 1)
110 Vol. 6 No. 2, April-June 2004
JK SCIENCE
* Respiratory rates (Level 1 in Paediatrics and (c) The initial contact is done before the transport
Level 2 in other patients) and it should be individualized; names and
In Selected Patients contacts of the participants in the process of
* Capnography (Level 2) transfer should be recorded.
* Continuous measure of blood pressure (Level 3) (d) Medical and nursing records and the
* Measure of the pulmonary artery pressure (Level 3) complementary diagnostic exams will be sent with
* Measure of Intracranial Pressure (Level 3) the patient.
* Measure of Central Venous Pressure (Level 3) 2. Choice of modes of transport should consider
* Measure of airway pressure in mechanically (a) Medical situations of patient (emergent, urgent/
ventilated patients (Level 1) elective)
Inter hospital transport of critically ill patients (b) Distance/timing of transport
Introduction (c) Necessary medical procedures during transport
* The main reason for the transport of a patient in (d) Staff availability and resources
a serious condition from a hospital to another (e) Weather forecast
one is the lack of diagnostic and therapy resources (f) In case of air transport it is also important to be
(human & technical) at the hospital of origin. aware of possible physiological changes regarding
* The decision of transporting a patient with these the altitude and its influence on clinical features.
characteristics is taken after evaluation of 3. Professionals to escort the patient
benefits and risks subject to transport. (a) Crew of the ambulance
* The risk of transport takes two parts. (b) Doctor with the nurse both with experience in
CPR and equipment
Medical risk:- The medical situation of the patient;
4. Equipment to serve the patient (7, 8)
vibration effects, acceleration-deceleration and changes
(a) Manual resuscitator and appropriate masks
of temperature.
(b) Mayotubes, laryngoscopes endotracheal tubes
Travel risk:- Vibration and collision risks.
and guide strings
* In order to minimize the risks of transport it is
(c) Oxygen source with appropriate capacity required
important to stabilize the patient at the hospital of
O2 = [(20+Vmin)xFiO2xTransport timing]+50%.
origin and do required diagnosis and therapies to
(d) Aspirator and Probes
prepare a safe trip (venous access, intubation etc.)
(e) Thoracic drains, introductions kit and accessories
Before the initiation of transport, the patient or his/her (f) Transport monitor and defibrillator
legal representative should be informed of the fact and (g) Automatic blood pressure reader and appropriate
an explanation of the situation, reason for transport, name armbands
of referral hospital should be given and when necessary (h) Material for puncture and maintenance of various
his/her agreement. lines (catheters, syringes and infusion systems)
1. Coordination before Transport (i) I/V fluids (crystalloids and colloids)
(a) Once the decision of transport is taken, it should (j) Drugs for advanced life support.
be done as soon as possible. (k) Transport ventilator with volume/minute,
(b) The doctor responsible should take care that all pressure, PEEP and FiO2 with reliable regulation
the required resources for the treatment are systems, capacity of monitoring of airway
available at the hospital of transfer. The service pressure, apnoea; high pressure and
expected to accept the patient should be fully disconnections alarm during the paediatric
informed of the medical situation and the transport the FiO2 and volume pressure should
predictable therapy procedures. be strictly controlled.