To transport or not to transport?
Moving ICU patients — both within and outside the hospital setting — requires that many critical decisions be made by anesthesiologists.
Transporting patients is typically a simple process — unless that patient happens to be in the ICU. In that instance, it can be one of the most dangerous situations an anesthesiologist contends with in a hospital.
Tuesday’s session "Transporting ICU Patients: Keeping Them Safe" will explore the potential pitfalls of patient transport and what anesthesiologists need to know for ensuring the safety of these critical care patients.
Panelist Christine Doyle, MD, MBI, FASA, Anesthesiologist and Critical Care Specialist at O’Connor Hospital in San Jose, California, said one key factor is knowing when not to transport the patient. That decision-making will involve both clinical and ethical considerations. Besides ensuring the patient is stable enough to survive the transport, Dr. Doyle encourages a healthy review of ethical questions.
“Should we be doing this at all? Is this an end-of-life situation where we should be making sure the family has time to be with the patient? You need to think about what these different situations are, and be prepared to discuss with your colleagues about why [moving the patient] is not appropriate,” she said.
Surgeons and proceduralists often don’t quite get the whole picture in terms of what a patient is going through, Dr. Doyle said. That is where anesthesiologists should step in.
“Sometimes that’s our job: to be the ‘whole picture’ person,” she said. “I’ve had clinical situations where we’ve had both ethical and clinical issues, but the fact that you can do something doesn’t mean that you should do something. You have to look at the entire situation and assess for safety, for appropriateness, and make sure the patient and family understand all of the risks.”
The session will also dive into more specific areas, such as the best way to ventilate a patient during transport. Amanda Arnzen, MD, Assistant Professor in the Department of Anesthesiology at the University of Nebraska Medical Center in Omaha, will present real-world scenarios in which ventilating a patient isn’t always quite so straightforward.
“The typical scenario is having this critically ill patient, and Murphy’s law says you’ll be in the ICU that’s farthest away from the OR,” she said. “In those cases, you need to know some of the methodologies for preventing hypoxia and when a muscle relaxant, a PEEP valve, and/or travel ventilator would be necessary.”
Dr. Arnzen said training courses present middle-of-the-night emergencies for a reason: they are often modeled after real-world experiences.
“When everyone is in training and they do their oral boards, they always assume that the scenarios are made-up. They are not,” she said. “Most of the time, those scenarios extend from the [experiences of] the person who wrote the exam.”
Once the decision to transport is made, preparation is the next critical step. Mark Cheney, MD, a Volunteer Associate Professor in the Department of Anesthesiology at the University of Nebraska Medical Center, said there are many considerations for journey preparation, including determining the equipment and expertise needed for a safe transport.
“Just like every anesthetic, specific preparation for each patient movement may vary,” said Dr. Cheney, who is also a U.S. Air Force Critical Care Transport Physician. “An anesthesiologist must consider the patient’s condition, transport circumstances, and probable or possible events. These questions inform preparatory efforts.”
Patients with different conditions require different considerations when preparing to transport. Cindy Ku, MD, FASA, Anesthesiologist at Pacific Anesthesia in Honolulu, Hawaii, will discuss transporting patients requiring neurocritical care. This includes those with intracranial pathologies with elevated intracranial pressure who are at risk of brain herniation, and patients with intracranial vascular diseases with concerns of aneurysmal rupture.
“Moving these patients, who are often on life support, to and from the operating room and other locations (such as the CT/MRI scanner) presents a challenge in the potential disruption of the precarious balance of the patient’s state,” she said. “There are specific issues that need to be addressed in these patients, such as those who need to be transported with their ventilator versus a self-inflating bag and circuit, position of the patient during transport, and medications accompanying the patient.”
Cardiac care patients also have their own special set of considerations for transport. Oren Bernstein, MD, FASA, an Anesthesiologist at Pacific Anesthesia in Honolulu, Hawaii, said patients on vasoactive drips, mechanical circulatory support, or who are otherwise critically dependent on external devices present unique challenges.
“Transport [of these patients] can be a logistical nightmare — from the simple personnel challenge of pushing a bed, tower of pumps, and any mechanical circulatory support devices down the hallway and into elevators,” he said. “Ensuring patency of drips is crucial. Decisions on medical issues such as whether to continue the patient on the ICU ventilator and how to approach neuromuscular blockade must be made.”
