Pediatric and neonatal critical care transport: a comparison of therapeutic interventions

XIII Consenso SIBEN sobre Traslado Neonatal: Establecer protocolos estructurados para el proceso del traslado neonatal podría mejorar los desenlaces

La centralización de los partos de alto riesgo en los hospitales con el más alto nivel de atención es fundamental para ampliar el margen de seguridad materno-neonatal y mejorar los desenlaces. Por lo tanto, es altamente recomendable trasladar oportunamente a las pacientes gestantes portadoras de embarazos de alto riesgo y/o con amenazas de parto pretérmino a centros de atención terciaria, sin embargo, no siempre es posible anticipar los riesgos antenatalmente, lo cual resulta en la necesidad de trasladar a neonatos en estado crítico. Lamentablemente, la movilización de los recién nacidos compromete aún más su estado de salud, especialmente en los países latinoamericanos. El presente trabajo resume los resultados del XIII Consenso Clínico de SIBEN de Traslado Neonatal, en el cual colaboraron 65 miembros de SIBEN, neonatólogos y licensiados en enfermería de 14 países de Iberoamérica, que participaron activamente durante el 2022, antes, durante y después de la reunión presencial que se llevó a cabo en Mérida, Yucatán, México el 12 de noviembre del 2022. En esta reunión se consensuaron las recomendaciones aquí vertidas.

Procedural Interventions and Stabilization Times During Interfacility Neonatal Transport

OBJECTIVE

Transport teams perform multiple procedural interventions during the stabilization of critically ill neonates. The setting of this study was a national cohort of interfacility neonatal transports from nontertiary centers.

METHODS

A retrospective cohort study of neonatal transports having interventional procedures using the Canadian Neonatal Transport Network database during 2014 to 2016. Demographics and procedures associated with stabilization times ≤ 120 versus > 120 minutes were analyzed. Predictors of stabilization time were evaluated using multivariable logistic regression analysis.

RESULTS

Among 3,350 neonatal transports analyzed, the 3 most frequently performed procedures were peripheral intravenous insertion, arterial blood gas sampling, and endotracheal tube insertion, with success rates of 85.2%, 89.1%, and 95.3%, respectively. The frequency of procedures varied across gestational age subgroups, and success rates were lower for umbilical arterial catheter insertions. After adjustment for confounders, more invasive procedures and a higher number of interventions were associated with longer stabilization times.

CONCLUSION

The type and frequency of procedures performed had a significant impact on stabilization time. Any procedures that are nonessential for stabilization at the nontertiary center, such as umbilical arterial catheter insertion, could be minimized to promote timely admission to tertiary centers. The demonstrated variations in procedural success among teams provide useful information for benchmarking and promote the sharing of training practices.

Factors Affecting Stabilization Times in Neonatal Transport

OBJECTIVE

During transport, the time spent in stabilizing sick infants before repatriation is crucial in optimizing the outcome and effective use of resources. The study aim was to assess individual components of neonatal transport time to identify opportunities to minimize delay, optimize care, and improve the overall efficiency of transport.

METHODS

A single-center prospective observational study conducted at McMaster Children's Hospital, Hamilton, Ontario, Canada, with a dedicated transport team for over 12 months. The stabilization time was defined as the time interval between arrival and departure from the referring hospital.

RESULTS

Of 223 neonatal transfers, 67 required no procedural or therapeutic intervention before mobilization to the receiving unit, with a mean stabilization time of 113 ± 52 minutes. In 156 transport events, 1 or more interventions were required, with a significantly higher mean stabilization time of 165 ± 89 minutes (P < .0001).

CONCLUSION

This study found that the local stabilization time was more than 1.5 times that of the comparable published data. The reasons identified for this delay were mostly because of waiting times for vehicle mobilization, waiting for blood and radiology results, and bed availability. Modifying these factors could save up to 28% of the stabilization time.

The use of vasoactive agents via peripheral intravenous access during transport of critically III infants and children

OBJECTIVES

Many experts recommend that vasoactive agents be infused via a central venous line (CVL) because of the potential risk of infiltration, but CVL placement in pediatric patients is often challenging. We hypothesized that it is safe to administer vasoactive infusions via peripheral intravenous (PIV) line in critically ill infants and children during interhospital transport.

METHODS

We retrospectively reviewed the medical records of 1133 neonatal and pediatric patients transported to the intensive care units at Children's Hospital Boston from May 2004 through June 2006 to identify patients treated with vasoactive medications via PIV line. Mann-Whitney U analysis was used to identify variables associated with complications of peripheral vasoactive infusion.

RESULTS

Seventy-three (6%) of the 1133 patients were treated during transport with vasoactive agents via PIV line. No complications occurred during transport, but 11 (15%) of 73 patients developed intravenous (IV) infiltrates related to vasoactive infusion at a mean of 7 hours after arrival to the receiving facility (range, 2-24 hours). Compared with patients with IV infiltrations, those without IV infiltrates had significantly lower median duration of vasoactive infusion and median maximum medication dose (256 vs 810 minutes and 10 vs 15 microg/kg per minute, respectively; P < 0.05). There were no significant differences between any other variables tested, and all infiltrates resolved without significant intervention or lasting injury.

CONCLUSIONS

Results from our series suggest that administration of vasoactive medications via PIV line during transport of critically ill infants and children is safe. The risk for complications increased with higher infusion rates and longer duration of therapy. Prompt transitioning of vasoactive infusions to a CVL may lead to fewer complications but does not seem to be necessary before transport.

The pattern of intravenous drug administration during the transfer of critically ill children by a specialist transport team

BACKGROUND

There are few published data on the patterns of intravenous drug administration by specialist pediatric intensive care unit (PICU) transport teams during the transfer of critically ill children between hospitals.

METHODS

A retrospective review of retrieval documentation was undertaken for all patients transported by the Royal Manchester Children's Hospital PICU transport team over a period of 1 year.

RESULTS

A total of 257 patients were transported during the study period, 82 patients (32%) were excluded owing to incomplete or absent documentation, leaving a sample of 175 available for analysis. Intravenous drugs were administered to 168 of these patients (96%). In total, 38 different drugs were administered. The four most commonly administered drugs were midazolam (130 patients), morphine (129 patients), atracurium (108 patients), and heparin (53 patients). Ten drugs accounted for 90% of all prescription episodes (total number of infusions and bolus doses administered), whilst 16 drugs were prescribed only once. The mean number of drugs administered per patient was 3.25 with a mean of 1.96 drug infusions and 1.29 bolus drugs administered per patient.

CONCLUSIONS

A relatively small number of drugs are used frequently during the retrieval of critically ill children, but the total range of drugs that are used is large. This has implications for the rational carriage of drugs by PICU transport teams, the potential for drug errors and also for the development of advanced nurse practitioners whose prescribing-like activities may depend on the development of Patient Group Directions.

Effect of transport team interventions on stabilization time in neonatal and pediatric interfacility transports

INTRODUCTION

During interfacility transport, the length of time taken by the transport team to prepare the patient for transport is often perceived as a problem by referring hospital staff. The purpose of this study was to examine the effects on time at the referring hospital of the number and complexity of interventions performed by the transport team to stabilize the patient prior to transfer.

SETTING

Interfacility transfers by the provincial infant transport team (ITT) to British Columbia's Children's Hospital.

METHODS

This was a prospective study of emergency neonatal and pediatric interfacility transfers. After each transport, the team completed a questionnaire about interventions performed and stabilization time. Transports were classified by the complexity of interventions performed: none, low (intravenous line, blood gas, nasogastric tube, Foley catheter, oxygen administration), or high (intubation, central venous access, arterial lines, chest tube insertion).

RESULTS

Thirty of 55 transports required no intervention (mean stabilization time=52+/-25 min). Sixteen transports required low level intervention (mean=60+/-22 min). Nine transports required high level intervention (mean=140+/-52 min). The stabilization times for "no" and "low" levels of intervention were not significantly different (P=.3), but the time for "high" level intervention was significantly higher (P<.01).

CONCLUSIONS

The need for the transport team paramedics to perform high level interventions significantly increased the time at the referring hospital. In contrast, the time taken for them to perform or reperform low level interventions, whether one procedure or two, was not a significant source of delay.