Term 4 Week 11 (w/c 12/11/12)
Good morning. Welcome to a new week on Gasclass. Until now we have usually ended the term after 10 weeks but the team has decided to extend this term for at least a couple more weeks. We hope you are all still paying attention in class? Onto this weeks case…
You are the resident anaesthetist in a general hospital and you have been asked to transfer a patient from the critical care unit in your hospital to a tertiary refferal centre.
What are the important issues (or hazards) to be aware of when transferring a critically ill patient?
You find out some more information about the patient. They are currently ventilated in critical care and are being transferred by road approximately 15 miles for an upgrade of care.
It is rush hour (1700 hrs), dark outside and the ambient temperature is just above freezing (British summertime!)
As you prepare yourself, what drugs and equipment do you want to take with you. Think as laterally as you can?
You now have more details about the patient.
65 year old female.
She collapsed at work this evening having been well previously. Her admission GCS was e1 v1 m3. Both pupils were responsive
She was hypertensive on arrival with heart rate of 50 bpm
She has controlled hypertension and takes an ACE-I. Ex smoker but no other PMH of note.
She has been intubated and sedated in the ED. CT shows ICH with an acute SDH and mass effect (midline shift),
The neurosurgical team want her to be transferred ASAP.
What are the key components of safe and effective transfer of this patient? Is there anything else you want to do before the ambulance arrives?
You do not have to produce a complete answer in one tweet and it may be useful to see if we can reach a combined plan.
We will now look at one or more critical incidents that could occur en route
The monitor alarms and you note that the spO2 is falling
Describe what you would do next?
Ask the expert
This week we have spoken with Dr F who is at the end of his advanced training in Critical Care and has a specialist interest in transfer and retrieval of the critically ill patient.
This is clearly a time critical transfer and it is only a question of formality to have the patient accepted in a tertiary neuro centre. So allocate one registrar (A&E) to do the communication with neurosurgery and neuro icu. There should be critical care network agreements that formalise the referral and acceptance process. Keep yourself free to stabilise the patient, set her up on the transfer trolley and be ready to load her into the ambulance once accepted. Who should transfer? You should not only be experienced in transfer and itu, but also have sufficient experience in neuro-anaeshtesia /neuro-icu. Transfer equipment, monitoring and drugs are standard for neuro transfer. As this might not be in your standard transfer bag remember to have some hypertonic saline or mannitol (+ urinary catheter).
Document the pre-transfer checklist and keep a record during transfer including pupils, you might have to repeat mannitol. I usually sit closest to the patients head for a neuro transfer so I can check the pupils regularly. The chart can also be used as handover document. Make sure you keep a copy to complete the regional transfer audit, the chart is also useful to formally debrief your team. The communication should have established clearly whether to bring the patient to A&E, neuro icu or theatre (this is in order of increasing time efficiency). Blue light or not? I usually ask to transfer without blue light – this makes it safer for the patient and the team, but I ask the blue light/sirens to be switched on to get through stationary traffic.
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.