for example:

For safety, the litres calculated should be doubled as ventilation requirement may change during the journey.

Purpose-built vehicles and transport trolleys enable staff to house adequate supplies of oxygen and air for long journeys without the risk of error or a gas leak on route. Air-only adapters should be stored on vehicles or taken for use when ventilating neonates with congenital cardiac conditions.

Dedicated vehicles also enable additional equipment to be stored on vehicles to lighten backpacks. Safety equipment, such as torches and reflector jackets, can also be stored on vehicles in case of accidents.

Arrival at the Referring Hospital

Assessment and Stabilisation

On arrival at the DGH the child will be resuscitated and/or stabilised in an identified place of safety. These areas are usually identified by the referring DGH, which makes it easier for local teams to set up paediatric equipment in a permanent place. Identified places of safety also enable retrieval staff to locate the child easily. It also benefits the local team as they become familiar with the location of paediatric equipment. These areas are typically:

• Recovery.
  
• Operating theatres.
  
• General intensive care.
  
• Paediatric high dependency.
  
• Emergency units (if the child is too unstable to be moved).

Introductions to staff should occur at this stage. This is not only polite, it also makes clear who is in which role in an often frenetic environment. Resuscitation and stabilisation of a critically ill child are extremely stressful in an unfamiliar situation. The approach of the retrieval team should be calm and measured. This not only gives confidence to the family, if present, but can help to reduce the anxiety levels of the whole team.

A review of the history and an assessment of the child on arrival are essential. This confirms whether the referral information has been correctly conveyed and understood. The condition of a critically ill child can change rapidly and the differential diagnosis may need revision. The child needs to be reviewed using the ABC approach no matter what the provisional diagnosis.

The assessment process will identify anything that needs to be addressed immediately, and using the ABC approach ensures this is done methodically.

Once assessment is complete the retrieval team need to agree on a plan. This will include when it is safe to transfer the child to the transport trolley. This will vary depending on the severity of the illness and the extent of stabilisation the local team have been able to achieve prior to the retrieval team’s arrival. Some cases will have been comprehensively stabilised, while others will still be in the early stages of resuscitation. Experience in transportation has demonstrated that the more that is attached to the child once on the transport trolley, rather than before, the less likely the risk of displacement and entanglement of lines and equipment when the team is ready for departure.

However, retrieval should never be rushed, and eagerness to get the child on the trolley should not take priority over any stage in the assessment process. Securing of tubes and lines is critical before the transfer to trolley takes place.

Airway

The airway of a child being retrieved will usually be maintained with a endotracheal tube (ETT) as most retrieval services are commissioned to collect children of sickness levels 2 and 3 (DH 1997). DGH anaesthetists are responsible for the intubation of the critically ill child. Intubation may be reviewed by the retrieval team but should never be delayed awaiting their arrival.

The ETT maintaining the airway needs to be secured according to local policy. If the airway is not well secured at this time it needs to be taped again, as loss of the airway during transportation could be catastrophic. A chest X-ray should have been performed and should be reviewed prior to re-taping a tube. An ETT that is too short is vulnerable when moving critically ill patients so it should not be cut until the transport team reviews the chest X-ray.

Maintenance of the airway also depends on the sedation being continuously administered to the child during the stabilisation process. Transportation teams frequently use paralysing agents (see Chapters 4 and 13) so that the child will not lose their artificial airway during the transport process. For this reason the practitioner responsible for the security and functioning of the ET tube must ensure that placement is correct.

Breathing

The child that is intubated will be artificially ventilated using an ambu bag, Ayre’s T-piece, Water’s circuit or mechanical ventilator.

Chest movement should be assessed and should be easily viewed as equal and bilateral. The child should be breathing at a developmentally appropriate and comfortable rate. The chest needs to be auscultated to assess air entry, which should be equal and bilateral depending on aetiology and diagnosis.

The child that is agitated and breathing against the ventilator will be very evident as they will be causing the alarm on the ventilator to activate. These children are very difficult to manage. A child that is not compliant with ventilation will usually:

• Not be intubated correctly – ETT in oesophagus, too short or in one lung.
  
• Inadequately ventilated – low rate, low peak pressure levels or lack of PEEP (positive end expiratory pressure).
  
• Have a blocked airway – kinked tube or secretions.
  
• Be inadequately sedated.

Other items that may cause difficulty in ventilating the critically ill child in an environment that usually caters for adult patients are bacterial filters used to protect the patients and the machinery. Filters used in adults have large volumes. When used in infants these can result in the accumulation of carbon dioxide. Used together with a catheter mount, especially disposable-concertinaed brands, this can result in increased dead space and rebreathing of carbon dioxide.

Filters used in paediatrics have small volumes and maintain humidity. This is extremely important in the small diameter artificial airway as the moisture will prevent encrusting and potential blockage of the tube.

Transport ventilators can be used at this stage to stabilise the child while waiting for the retrieval team. However, some teams choose the ventilators that are used in their adult patients as staff are more confident in their use. Most of these have paediatric modes and may be the safest option.

Few transport ventilators are available in the United Kingdom. Two types are commonly used: for under 10 kg and for over 10 kg. The under 10 kg Smiths babyPAC ventilators are flow-dependent and very simple to use. Older children are ventilated using either a Smiths ventiPAC or the Drager Oxylog ventilator. There are multiple models of the latter in use. Newer models are electrically dependent.

Blood gases should be recorded once ventilation is established and when changing methods of ventilation. Handheld gas monitors are available for use during transportation. All blood samples, including cultures, should be taken for analysis at the referring hospital to establish the baselines and ensure any abnormalities are treated as promptly as possible.

Circulation

On the arrival of the retrieval team the child will be attached to the local monitoring systems. These usually have universal parameters, which can be assessed immediately by an experienced intensive care team. Vital signs, along with a central capillary refill time, will give staff the information required to assess current circulatory status.

The minimum acceptable access for transportation is two functioning venous cannula. Ideally, these will be 22 gauge as the 24 gauge will not provide adequate access to the circulation of the critically ill child should the child deteriorate.

Inotropic dependent children and those that will require multiple interventions will require central access, and for safety reasons this should be obtained prior to transporting this type of case. These lines offer multiple lumens so that numerous infusions can be administered.

Arterial access monitoring blood pressure is also desirable as it gives the team an immediate indication of changes in the child’s cardiovascular status.

All of these devices will need to be well secured with time taken for comprehensive strapping to ensure that they do not become dislodged during any bed-to-bed manoeuvres. Sutures are frequently used to retain these lines in addition to tape dressings. Easy visibility of these lines is still desirable so bandages should be discouraged.

It is usually evident quite quickly if a child has high fluid requirement to resuscitate them. These cases will need urgent cross-match of blood products in their local hospital to avoid over-dilution of their circulatory system.

Drug infusion dosages should be checked at this time to ensure that the child is getting the correct dosages of inotropes and other infusions. PICUs tend to calculate infusions as mg/mcg/kg/hr/min. This method of calculation is not always used in other clinical areas and can be miscalculated in stressful scenarios.

Disability

Assessment of the critically ill child should always include assessment of the neurological system. The administration of sedatives and paralysing agents for intubation make this difficult. Therefore the child’s pupil status should always be assessed. This gives the team a baseline and any changes in neurological status can be quickly identified.

Glucose levels should also be checked at this stage and any abnormality treated.

Due to the extremely stressful nature of resuscitating critically ill children there may be a point where a review of what has been done is needed. At this point a medication review can take place to ensure antibiotics, etc., have been given. Even experienced staff can find it difficult to remember all of these aspects of treatment because of the pace of the activity.

Prior to Departure

Equipment required for duration of the journey needs to be well planned so that the team are prepared for most eventualities.

Airway

Airway replacement equipment needs to be prepared and placed in an accessible place in the transport vehicle. This tray should contain:

• Stethoscope.
  
• ET tube (the size in the child’s airway and one size below).
  
• Laryngoscope (age appropriate).
  
• Guedel airway (age-appropriate).
  
• Ambu bag.
  
• Clear mask.

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