The ITU Nurse.

I am Mike.
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Kiddie Intensive Care Nurse.
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Transferring the critically ill patient: What you should know

Why do we transfer outside?

  • Lack of capacity
  • Lack of resources
  • Specialist treatment
  • Specialist investigation
  • Transfer to local hospital

Why do we transfer within the hospital? 

  • CT scans
  • MRI scans
  • Theatre
  • Radiographic procedure
  • Transfer to other ward/specialty

Why worry about transferring your patient? 

Often, our patients are the sickest within the hospital.   Thus, they are the most unstable with an unclear diagnosis.  A patient who is stable on minute can change completely hemodynamically the next.   En route, simple things like remember syringe driver cables and extra medications are a must. 

11,000 patients require transfers within hospital per year.  5-10% of those are transferred to an ICU.  88% are transferred with a junior doctor. 97% are escorted by an anaesthetist.  And almost half the time (45%) the faults which occur are equipment related. 

However, the actually movement of the patient causes instability.  Up to 75% of patients may suffer adverse effects where as up to 50% may experience a potentially life threatening change. 

Guidelines?  

  • Comprehensive Critical Care (Dept of Health, 2000)
  • "Guidelines for the transport of the critical ill adult" (ICS, 2002).

In a perfect world, an experienced nurse and an airway trained doctor would transfer the patient.   And always transferred with at least 2 people.

What happens in transfer? 

Due to the changes in posture (acceleration and deceleration forces) the circulation adapts. Heart rate, stroke volume resistance and venous tone can all alter, if your patient is sedated -  these mechanisms are impaired. 

Remembering all sedatives reduce heart rate and myocardial contractility as well as vasodilation (which may cause hypotension). 

What to do if  cardiovascular changes occur?

  • Heart rate
     - Nothing unless <60bpm
  • Contractility
     - Optimize filling
  • SVR
     - Vasopressor (meteraminol/noradrenaline)

 What does mechanical ventilation do to the cardiovascular system?

  • Venous return falls
  • Contractility falls
  • Stroke volume falls
  • Blood pressure falls
  • Fill prior to movement to optimise patient
  • +/- vasopressor

Respiratory effects of ventilation?

  • V/Q mismatch
  • Alveolar collapse
  • Volu/Baro trauma
  • Pneumonia

We can?

  • Ensure adequate tidal volume (TV) (6-8mls/kg)
  • Avoid excessive TV
  • Apply PEEP
  • Increase FiO2

It makes no difference whether you are going 100metres or 100miles - the preparation should be the same. Keep the head elevated (if not c-spine trauma), move them gently and ensure they are well filled.

Before transfer it would be wise to asses ABCDE, do a transfer checklist - ensure you are prepared.  The emergency bag you will take with you  - I bet is a complete mess, check what and where is in the bag before you go so you can replace items that will be missing.

Airway:

Pre transfer:

  • Secure
  • If GCS  <8 intubate
  • If PO2 <8Kpa intubate

Pre and in-transit:

  • Suction
  • Spare airway equipment incase of loss of airway 
  • Bag/valve/mask
  • Personnel

Breathing:

  • Ensure adequate blood gas before departure
  • If changing to a mobile ventilator attach patient at least 15 minutes prior to transfer to asses synchrony. 
  • New literature states it is better to unclamp a chest drain when transferring.  Only clamp when the drain raises above the level of the patient. However  - check your local policy. 

Circulation:

"Full patients travel better"

  • Give fluids for CVP and perfusion
  • MAP >75mmHg
     - Systolic BP >120mmHg
  • Pulse <120/min
  • 2x large cannula (if no access on central line or no central line at all) minimum
  • Volume - is it wise to take a pump with you incase?
  • Catheterise the patient if not contraindicated

Disability:

  • Asses GCS
  • Sedate and muscle relax depending on situation
  • Monitor for seizure activity
  • If they have a  raised ICP (intracranial pressure) keep MAP >90mmHg and ensure the patient is deeper sedated
  • Check blood sugar level

Exposure:

  • Temperature 
  • When transferring patients generally get cold
     - Which causes vasoconstriction, which increases the risk for pulmonary oedema
  • Pad pressure points/areas
  • Lines/Access
     - Secure?
     - How old?
     - Where? 

Sometimes special transfers (neurological or vascular) require separate parameters for the patient to ensure perfusion and stability. 

Neuro:

  • ETT must be taped around the mouth, not neck.  When done around the neck venous return is restricted as well as cranial drainage. It also increases ICP.
  • Well oxygenate the patient
  • To run at a lower end of CO2 is acceptable
  • EtCO2 monitoring is a must
  • MAP >90mmHg
  • Femoral CVC so not to occlude the neck
  • Head raised 30 degrees - if not contraindicated

Vascular:

  • BP 70-100mmHg systolic
  • Pulse <100bpm
  • Minimal fluid resuscitation

_______________________________________

ENSURE you have adequate amounts of oxygen for transfer.  - Check cylinder capacity and calculate usage/min  - a 480litre bottle (if full) will only last you 48 minutes on 10l/min. THINK.
_______________________________________

Monitoring and Equipment:

Monitor - 

  • ECG monitor
  • NIBP/Arterial line
  • SaO2
  • EtCO2 (if ventilated)
  • Temperature 

Ventilator

Knowledge of equipment -

  • Batteries, leads and inverter
  • Defibrillator
  • Suction unit
  • Tracheotomy kit
  • Transfer bag

Organisation & Communication:

  • Call other department/area
  • Alert transfer team
  • Confirm time
  • Confirm location
  • Patient/relatives
  • Ambulance service and porters - If you call for an emergency transfer out of hospital, an ambulance aims to be with you in 15 minutes - do not call until you are ready. 

Medical & Legal Issues:

  • Does the patient want to transfer?
  • Intention of transfer?
  • Responsibility on transfer
  • Safety and insurance of transfer staff.

Summary: 

  • Risks come with transferring
  • Physiological changes can and probably will occur
  • PREPARATION IS KEY


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