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BACKGROUND: Acute mechanical circulatory support (aMCS) can be a lifesaving therapy for patients with refractory cardiogenic shock. As device safety and technology improve, so will the ability to extend aMCS to patients at remote hospitals. The Intermountain West is unique because of the large geographical area, making transport of critically ill patients a logistical challenge. METHODS: We reviewed our experience of transporting patients in cardiogenic shock over long distances who had already been placed on aMCS: Impella and extracorporeal membrane oxygenator devices. Survival data was compared to international benchmark data published by the Extracorporeal Life Support Organization. RESULTS: A total of 11 patients (91% male; mean age 56 ± 5.4 y) were transported via fixed-wing aircraft to our center. The etiology of cardiogenic shock was ST-elevation myocardial infarction (n = 4), acutely decompensated chronic systolic heart failure (n = 4), postcardiotomy shock (n = 2), and acute myocarditis (n = 1). Average transport distance was 364 ± 139 miles (585 ± 264 km) and flight time was 170 ± 29 min. All patients were safely transported with no in-transit adverse events. The average duration of aMCS was 6.4 ± 3.3 d. Six patients (54.5%) survived to device explantation and 3 (27.2%) survived to hospital discharge. For comparison, Extracorporeal Life Support Organization benchmark data for adult cardiogenic shock patients report 56% survival to device explantation and 41% to hospital discharge. CONCLUSIONS: Patient transport with aMCS over long distances can be done safely without serious adverse events using good protocols and well-trained personnel. Although survival data are slightly below benchmark data, they appear reasonable, given the severity of illness and challenges of transferring critically ill patients to an expert center.

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Oxigenación por Membrana Extracorpórea , Transferencia de Pacientes , Choque Cardiogénico/terapia , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente

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The optimal staffing model during the inter-hospital transfer of patients on extracorporeal membrane oxygenation (ECMO) is not known. We report the complications and outcomes of patients who were commenced on ECMO at a referring hospital by intensive care physicians and compare these findings with patients who had ECMO established at an ECMO center in Australia. This was a single center, retrospective observational study based on a prospectively collected ECMO database from Melbourne, Australia. Patients with severe cardiac and/or respiratory failure failing conventional supportive treatment between 2007-2013 were placed on ECMO via a physician-led model of ECMO retrieval, including two intensivists in a four person team, using percutaneous ECMO cannulation. Patients (198) underwent ECMO over the study period, of which 31% were retrieved. Veno-venous (VV)-ECMO and veno-arterial (VA)-ECMO accounted for 27 and 73% respectively. The VA-ECMO patients had more intra-transport interventions compared with VV-ECMO transported patients, but none resulting in serious morbidity or death. There was no overall difference in survival at 6 months between retrieved and ECMO center patients: VV-ECMO (75 vs. 70%, P = 0.690) versus VA-ECMO (70 vs. 68%, P = 1.000). An intensive care physician-led team was able to safely place all critically ill patients on ECMO and retrieve them to an ECMO center. This may be an appropriate staffing model for ECMO retrieval.

Asunto(s)

Cuidados Críticos , Oxigenación por Membrana Extracorpórea , Insuficiencia Cardíaca/terapia , Insuficiencia Respiratoria/terapia , Adulto , Australia/epidemiología , Cuidados Críticos/métodos , Enfermedad Crítica/epidemiología , Oxigenación por Membrana Extracorpórea/efectos adversos , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Médicos , Insuficiencia Respiratoria/epidemiología , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del Tratamiento

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Extracorporeal membrane oxygenation (ECMO) may be a life-saving procedure for patients with severe reversible pulmonary or cardiac failure or for patients in need for a bridge to transplantation. ECMO is provided by specialized centers, but patients in need of ECMO are frequently taken care of at other centers. Conventional transports to an ECMO center can be hazardous and deaths have been described. For this reason, many ECMO centers have developed transport programs with mobile ECMO. After request, the mobile team including all necessary equipment to initiate ECMO is sent to the referring hospital, where the patient is cannulated and ECMO commenced. The patient is then transported on ECMO to the ECMO facility by road, helicopter, or fixed-wing aircraft depending on distance, weather conditions, etc. Eight publications have reported series of more than 50 transports on ECMO of which the largest included over 700. Together, these papers report on more than 1400 patient transports on ECMO. Two deaths during transport have occurred. A number of other adverse events are described, but without effect on patient outcome. Survival of patients transported on ECMO is equivalent to that of non-transported ECMO patients. It is concluded that long-, short-distance interhospital transports on ECMO can be performed safely. The staff should be experienced and highly competent in intensive care, ECMO cannulation, ECMO treatment, intensive care transport, and air transport medicine.

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Objective Through death analysis of critically ill children with interhospital transportation,to explore the cause of death and its influencing factors.Methods We collected the data of death cases within 24 hours who were one-way transported from primary hospital to the emergency department of Guangzhou Women and Children's Medical Center between July 2012 and May 2014.We analyzed the diseases type,physiopathologic status,and the treating measures in the process of transportation.Results There were total 1 122 cases,34 children died,the mortality was 3.0％,7 cases died before admission,27 cases died within 24 hours after admission.The first three types of diseases were respiratory system diseases(8/34,23.5％),nervous system diseases (7/34,20.6％) and accidental injury (6/34,17.6％).The physiopathologic status were analyzed according to physiological status and laboratory data at admission.Most of the children had a variety of physiopathologic status.Electrolyte disturbances were found in 22 cases(81.5 ％),metabolic acidosis and respiratory failure in 19 cases (70.4％).Most cases had intravenous channel (33/34,97 ％),intravenous infusion (32/34,94.1％)and electrocardiogram monitoring (30/34,88.2％),none of the cases received vasoactive agents in transportation.Conclusion Insufficient disease evaluation before the transportation of critically ill children,inadequate monitoring and treating measures on the way are important factors causing the death of children.

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Objective To evaluate the mode of referral by response time for inter-hospital transfer of critically ill pediatric patients,and subsequently some measures taken for minimizing the response time in referral process.Methods A total of 9231 patients (≤14 years) transferred from primary hospital were included in a cross-section study.Information about age,sex,referral radius,the seasonal variation for inter-hospital transport of critically ill pediatric patients,time of referral telephone call and response time were collected.All computations were performed using the Statistic Package for Social Sciences for Windows version 18.0.Differences between groups were assessed by x2 tests or Wilcoxon test or Kruskal-Wallis for categorical data.Results Among all critically ill pediatric patients for the inter-hospital transfer,male to female ratio was 2.24:1,and the majority of patients were neonates and infants.Median retrieval mobilization time was 30 min (interquartile range,20-50 min).This study has demonstrated that referral time,age categories,referral radius,different years and seasons were associated with response time.Conclusions With the improvement of technologies and management mechanism,the response time was apparently minimized since the beginning of interhospital transportation.But there is still plenty of room for shortening rsponse time compared with advanced Westem countries.

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Objective The purpose of this study was to evaluate the importance of the interhospital transport of critically ill pediatric patients by analyzing the epidemic characteristics of pediatric patients transported from 2009 to 2012.Methods Nine thousand two hundred and thirty-one referral patients from January 2009 to June 2012 were evaluated by a cross-section study.Epidemiological data such as sex,age,seasons,and referral radius were collected.Results Among all the interhospital transport of critically ill pediatric patients,male to female ratio was nearly 2.24 to 1 and 87.39％ (8067/9231) patients were neonates and infants.Of all patients,66.32％ (6122/9231) patients were from department of pediatrics,neonatology or gynaecology and obstetrics in referring hospitals.The distribution of referring department among years was statistically significant in referring patients (x2 =227.53,P ＜ 0.000 1).Among the patients,56.88％ (5251/9231) were transported over 150km radius and only 12.18％ (1124/9231) patients in 50 km.52.89％(4882/9231) were transported in spring and winter.The seasonal distribution of interhospital transport of critically ill pediatric patients was statistically significant(x2 =1201.88,P ＜0.000 1).The majority of referral telephones were received between 9 AM to 12 AM.Conclusion With the limitation of equipment and technical measure in primary hospitals,critically ill pediatric patients should be transported to tertiary hospitals.According to the epidemiological characteristics of interhospital transport of critically ill pediatric patients,some measures should be adopted for the timely,safe and effective interhospital transportation.