Cuidar da pessoa em situação critica no serviço de urgência: contributos do enfermeiro especialista para a qualidade dos cuidados / Caring for the critically ill person in the emergency department: the specialist nurse's contribution to the quality of care

Este relatório de estágio surge no âmbito do curso de Mestrado em Enfermagem Médico- Cirúrgica e pretende evidenciar as experiências e atividades desenvolvidas no sentido de adquirir e desenvolver competências especializadas. A estrutura do relatório teve como linha orientadora os domínios de competências definidas para o Enfermeiro Especialista pela Ordem dos Enfermeiros, enquadradas nos domínios académicos preconizados pela Instituição de Ensino. O perfil de conhecimentos e competências do Enfermeiro Especialista na área da pessoa em situação crítica deve responder de forma competente à frágil e complexa situação clínica, sendo o seu papel suportado por um quadro de competências diferenciadas enquadradas no respeito pelo Ser Humano e pelos seus direitos inalienáveis. Focados no crescimento e desenvolvimento de competências especificas na área da pessoa em situação crítica, bem como no contributo da visão diferenciada do Enfermeiro Especialista na melhoria da qualidade dos cuidados, procuramos dar resposta aos problemas encontrados na prática clínica. Das atividades desenvolvidas destacamos a criação de um fluxograma de apoio ao enfermeiro triador no encaminhamento interno dos doentes e de um protocolo terapêutico de atuação no adulto com febre na triagem de manchester. Evidenciamos também, o investimento resiliente no desenvolvimento e implementação de um protocolo complexo, no âmbito da prestação de cuidados em contexto de urgência, ao doente em estado de agitação/agressividade que visa mitigar um problema recorrente. No domínio académico da investigação desenvolvemos um estudo qualitativo com recurso à técnica de Focus Group, com o objetivo de construir um modelo de documentação padronizado, simplificado e facilitador do registo de enfermagem que documente a atuação do enfermeiro na avaliação e intervenção ao doente, durante o transporte inter-hospitalar. As conclusões deste estudo de investigação validaram um modelo de registo sustentado numa mnemónica, uniformizadora e facilitadora dos registos de enfermagem durante o transporte inter-hospitalar do doente crítico. Consideramos que as experiências que decorreram deste estágio foram fundamentais e permitiram o desenvolvimento das competências inerentes ao Enfermeiro Especialista.

This internship report appears within the scope of the Master's degree in Medical-Surgical Nursing and aims to highlight the experiences and activities developed in order to acquire and develop specialized skills. The structure of the report was guided by the domains of competences defined for the Specialist Nurse by the Order of Nurses, framed in the academic domains recommended by the Educational Institution. The profile of knowledge and skills of the Specialist Nurse in terms of people in critical situations must respond competently to the fragile and complex clinical situation, with their role supported by a framework of differentiated skills framed in respect for the Human Being and their inalienable rights . Focused on the growth and development of specific skills in the area of people in critical situations, as well as the contribution of the Specialized Nurse's differentiated vision to improving the quality of care, we seek to respond to problems encountered in clinical practice. The activities developed highlight the creation of a flowchart to support the triage nurse in the internal referral of patients and a therapeutic protocol for working with adults with fever in the manchester triage. We also highlight the resilient investment in the development and implementation of a complex protocol, within the scope of providing care in an emergency context, to patients in an agitated/aggressive state that aims to mitigate a recurring problem. In the academic domain of research, we developed a qualitative study using the Focus Group technique, with the objective of building a standardized, simplified documentation model that facilitates the nursing record that documents the nurse's role in evaluating and intervening with the patient, during the inter-hospital transport. The conclusions of this research study validated a recording model based on a mnemonic, standardizing and facilitating nursing records during the inter-hospital transport of critically ill patients. We consider that the experiences that took place during this internship were fundamental and allowed the development of skills inherent to Specialist Nurses.

[Application of transport ventilator in the inter-hospital transport of critically ill children]. / è½¬è¿å‘¼å¸æœºåœ¨å±é‡æ‚£å„¿é™¢é™ è½¬è¿ä¸­çš„åº”ç”¨ç ”ç©¶.

OBJECTIVES: To study the application value of transport ventilator in the inter-hospital transport of critically ill children. METHODS: The critically ill children in Hunan Children's Hospital who were transported with or without a transport ventilator were included as the observation group (from January 2019 to January 2020; n=122) and the control group (from January 2018 to January 2019; n=120), respectively. The two groups were compared in terms of general data, the changes in heart rate, respiratory rate, and blood oxygen saturation during transport, the incidence rates of adverse events, and outcomes. RESULTS: There were no significant differences between the two groups in sex, age, oxygenation index, pediatric critical illness score, course of disease, primary disease, heart rate, respiratory rate, and transcutaneous oxygen saturation before transport (P>0.05). During transport, there were no significant differences between the two groups in the changes in heart rate, respiratory rate, and transcutaneous oxygen saturation (P>0.05). The incidence rates of tracheal catheter detachment, indwelling needle detachment, and sudden cardiac arrest in the observation group were lower than those in the control group during transport, but the difference was not statistically significant (P>0.05). Compared with the control group, the observation group had significantly shorter duration of mechanical ventilation and length of stay in the pediatric intensive care unit and significantly higher transport success rate and cure/improvement rate (P<0.05). CONCLUSIONS: The application of transport ventilator in the inter-hospital transport can improve the success rate of inter-hospital transport and the prognosis in critically ill children, and therefore, it holds promise for clinical application in the inter-hospital transport of critically ill children.

Safety issues with an inter-hospital transport of a patient with a Berlin Heart Excor biventircular assist device.

BACKGROUND: Interhospital transfers of pediatric patients on the Berlin Heart Excor have been published on an occasional basis. METHODS: Nowadays medicine evolves away from just feasibility towards quality and safety issues. Management tools like risk analysis have found their way into clinical practice. RESULTS: Exemplary, we present a case of a 20 months old boy on a Berlin Heart BiVAD Excor who underwent a 224 km ground transport. After a systematic review of the published literature, we describe our safety management with the aim was to provide highest quality of care for the transport. CONCLUSION: Besides a risk analysis, we also describe our training and simulation protocol.

Application of transport ventilator in the inter-hospital transport of critically ill children / 中国当代儿科杂志

OBJECTIVES@#To study the application value of transport ventilator in the inter-hospital transport of critically ill children.@*METHODS@#The critically ill children in Hunan Children's Hospital who were transported with or without a transport ventilator were included as the observation group (from January 2019 to January 2020; n=122) and the control group (from January 2018 to January 2019; n=120), respectively. The two groups were compared in terms of general data, the changes in heart rate, respiratory rate, and blood oxygen saturation during transport, the incidence rates of adverse events, and outcomes.@*RESULTS@#There were no significant differences between the two groups in sex, age, oxygenation index, pediatric critical illness score, course of disease, primary disease, heart rate, respiratory rate, and transcutaneous oxygen saturation before transport (P>0.05). During transport, there were no significant differences between the two groups in the changes in heart rate, respiratory rate, and transcutaneous oxygen saturation (P>0.05). The incidence rates of tracheal catheter detachment, indwelling needle detachment, and sudden cardiac arrest in the observation group were lower than those in the control group during transport, but the difference was not statistically significant (P>0.05). Compared with the control group, the observation group had significantly shorter duration of mechanical ventilation and length of stay in the pediatric intensive care unit and significantly higher transport success rate and cure/improvement rate (P<0.05).@*CONCLUSIONS@#The application of transport ventilator in the inter-hospital transport can improve the success rate of inter-hospital transport and the prognosis in critically ill children, and therefore, it holds promise for clinical application in the inter-hospital transport of critically ill children.

Aeromedical interhospital transport of an adult with COVID-19 on extracorporeal membrane oxygenation: case report / Transporte aeromédico inter hospitalario de adulto con COVID-19 en oxigenación por membrana extra corpórea: reporte de caso / Transporte inter-hospitalar aeromédico de adulto com COVID-19 em oxigenação por membrana extracorpórea: relato de caso

Abstract Objective: To describe the experience of aeromedical interhospital transport of an adult patient with severe hypoxemic respiratory failure due to SARS-CoV-2, on extracorporeal membrane oxygenation. Method: This is a case report, guided by the tool Case Report Guidelines, with a descriptive approach. Data were collected from the digital medical record and field notes after the approval by the Institution and the Human Research Ethics Committee. Results: The transport of a critically ill, unstable patient with acute respiratory syndrome 2 on extracorporeal oxygenation was an opportunity for the team to acquire new knowledge. The proper preparation of the fixed-wing aircraft and the profile of the team of specialist nurses contributed to the safety and quality in the three phases of flight: preflight, in-flight and post-flight. Conclusion: Air transport of adults on cardiopulmonary bypass to referral centers, under the care of an experienced multidisciplinary team, can contribute to positive results. The nurses' autonomy, their leadership role and expertise in process management are highlighted. Thus, success was evidenced with the patient's discharge after 45 days from the Intensive Care Unit.

RESUMEN Objetivo: Describir la experiencia del transporte inter hospitalario aeromédico de un paciente adulto, con hipoxia grave por SARS-CoV-2, en uso de membrana de oxigenación extra corpórea. Método: Reporte de caso, guiado por la herramienta Case Report Guidelines, con abordaje descriptivo. Los datos fueron recolectados del historial clínico digital del paciente y de los apuntes de campo tras aprobación hecha por la Institución y por el Comité de Ética e Investigación con Seres Humanos. Resultados: El transporte del paciente en estado grave, instable, con síndrome respiratoria aguda 2 en uso de oxigenación extra corpórea fue una oportunidad para el equipo asimilar nuevos conocimientos. La preparación adecuada de la aeronave de ala fija y el perfil del equipo de enfermeros expertos contribuyeron para realizar con seguridad y calidad las tres etapas del vuelo: antes, durante y después del vuelo. Conclusión: El transporte aéreo de adultos a los centros de referencia en circulación extra corpórea, bajo los cuidados de un equipo con diversos profesionales experientes, puede ser contributivo para los resultados positivos. Se pone de relieve la autonomía de los enfermeros, el rol de liderazgo y la expertise en el manejo de procesos. Para tal, el éxito fue evidenciado por el alta al paciente después de 45 días en Unidad de Cuidados Intensivos.

RESUMO Objetivo: Descrever a experiência do transporte inter-hospitalar aeromédico de um paciente adulto, com insuficiência respiratória hipoxêmica grave por SARS-CoV-2, em uso de membrana de oxigenação extracorpórea. Método: Relato de caso, norteado pela ferramenta Case Report Guidelines, com abordagem descritiva. Os dados foram coletados do prontuário digital e do diário de campo após aprovação feita pela Instituição e pelo Comitê de Ética e Pesquisa com Seres Humanos. Resultados: O transporte do paciente em estado crítico, instável, com síndrome respiratória aguda 2 em uso de oxigenação extracorpórea foi uma oportunidade para a equipe assimilar novos conhecimentos. O preparo adequado da aeronave de asa fixa e o perfil da equipe de enfermeiros especialistas contribuíram para realizar com segurança e qualidade as três fases de voo: pré-voo, durante o voo e pós voo. Conclusão: O transporte aéreo de adultos para os centros de referência em circulação extracorpórea, sob os cuidados de uma equipe multiprofissional experiente, pode contribuir para os resultados positivos. Destaca-se a autonomia dos enfermeiros, o papel de liderança e a expertise no gerenciamento de processos. Para tal, o sucesso foi evidenciado pela alta do paciente após 45 dias do Centro de Terapia Intensiva.

Efficacy of comprehensive warming intervention strategy on gestational age <32 weeks preterm infants' body temperature during inter-hospital transportation / 中国新生儿科杂志

Objective:To study the effects of comprehensive warming intervention strategy on the body temperature of preterm infants (gestational age <32 weeks and birth weight <1 500 g) during inter-hospital transportation.Method:From October 2016 to July 2019, eligible preterm infants transported to our hospital were retrospectively analyzed. From October 2016 to March 2018, preterm infants transported with routine transportation strategy were assigned into the control group. From April 2018 to July 2019, preterm infants transported with the comprehensive warming intervention strategy were assigned into the experiment group. The body temperature, complications and prognosis before and after the transportation to our NICU were compared.Result:A total of 1 194 premature infants with gestational age <32 weeks were included with 630 cases in the control group and 564 cases in the experiment group. No significant differences existed in demographic data of the mothers, infants and the transportation time between the two groups ( P>0.05). The body temperatures before and after transportation in the experimental group were (36.8±0.5)℃ and (36.7±0.5)℃, significantly higher than the control group [(36.0±0.4)℃ and (36.3±0.6)℃] ( P<0.01). The incidences of hypoglycemia and mortality in the experimental group were 3.7% (21/564) and 4.8% (27/564), significantly lower than the control group [8.4% (53/630) and 7.9% (50/630)] ( P<0.05). Conclusion:Comprehensive warming intervention strategy in inter-hospital transport can effectively improve the body temperature of preterm infants before and after transportation, reducing the incidences of hypoglycemia and mortality.

The clinical features of patients: transfered by "Qilu " interhospital transfer center / 中华急诊医学杂志

Objective To explore new models for interhospital transfer and provide theoretical basis for the interhospital transfer system construction through analyzing the clinical features of the patients transfered by "Qilu" interhospital transfer center.Methods Totally 258 patients aged over 18 years who were transferred to or from Qilu Hospital of Shandong University from August 2014 to December 2016 were analyzed.The data including sex,age,transport index,modified early warning score (MEWS) and outcome of patients with successful transport were collected.According to the results,the transferred patients were divided into the improved group and the non-improved group,and the differences of the above indicators between the two groups were analyzed.In the numerical variable analysis,Student's t test or Mann-whitney non-parametric test was applied,and the categorical variable was applied with x2 test.The correlation between clinical indicators and outcomes of the patients was analyzed by logistic regression analysis.Results The total transfer success rate was 98.5％.The transported male patients were more than female patients.Patients transferred to Qilu Hospital were mainly diagnosed with nervous system disease,trauma and circulatory system disease,and patients transferred from QiLu Hospital were respiratory disease,circulatory system disease,and nervous system disease.Tracheal intubation,tracheotomy,and invasive mechanical ventilation rates were 11.9％-22.2％.The patients ratio of transferred from Qilu Hospital with vasoactive drugs and the ratio of patients with deep venous catheter were three times and five times than those transferred to Qilu Hospital.Eighty-one percent patients transferred to Qilu Hospital recovered,and 45.5％ patients transferred from the hospital recovered.The age,heart rate,MEWS score,length of stay,ICU ratio,mechanical ventilation ratio and tracheal intubation ratio were significantly different between the improved group and the non-improved group (P＜0.05).Among the critically patients transferred to ICU,the length of stay was correlated with the outcome of the improvement.(OR=1.213,95％CI:1.085-1.357).Conclusions "Qilu" Interhospital Transfer Center has a high success rate and high recovery rate of patients,and can be a new model for the construction of interhospital transfer system.

The study of extremely low and very low birth weight infant transport risk assessment and factors that influenced deaths / 中国新生儿科杂志

Objective To study the transport risk and factors that influence deaths of very low birth weight (VLBW) and extremely low birth weight (ELBW) infants.Method All infants transferred to our neonatal intensive care unit (NICU) by our hospital transport team or local hospital transport team from January 2014 to December 2015 were included in our study.Their clinical data were retrospectively studied.The risks of transport between hospitals were analyzed.The risk factors of deaths within and after 7 days of admission were further analyzed by multivariate Logistic regression analysis.The receiver operation characteristic (ROC) curve was used to assess the sensitivity and specificity of mortality index for neonatal transportation (MINT),transport related mortality score (TREMS),transport risk index of physiologic stability (TRIPS) for predicting mortality of preterm infants.Result (1) A total of 527 cases of ELBW/VLBW infants were included in our study.There were no deaths during transport.There were 10.2％ (54/527) died within and 8.9％ (42/473) died after 7 days of hospitalization.(2) Multivariate Logistic regression analysis showed that scleredema of newborn,secondary transport,gastrointestinal malformations,metabolic acidosis,high TREMS score,and high MINT score were risk factors of mortality within 7 days of admission for ELBW/VLBW infants;necrotizing enterocolitis,intraventricular hemorrhage ≥ three degree,high MINT score and low admission weight were risk factors of mortality after 7 days of admission.(3) The area under the ROC curve for MINT,TREMS,and TRIPS score were 0.672,0.655 and 0.665,respectively.The cut-off values for MINT score (cut-off 8,sensitivity 0.444,specificity 0.829),for TREMS score (cut-off 2,sensitivity 0.500,specificity 0.757,for TRIPS score (cut-off 20,sensitivity 0.444,specificity O.829) were selected to predict mortality within 7 days of admission.Conclusion (1) Secondary transport is the transport-related risk factor of mortality within 7 days of admission for ELBW/VLBW infants.(2) High MINT score is the risk factor of mortality within and after 7 days of admission.(3) If MINT ≥ 8,TREMS ≥2,or TRIPS ≥20,it might significantly increase the risk of mortality of ELBW/ VLBW infants within 7 days of admission after transport.

Inter-hospital transport of the child with critical cardiac disease.

Centralisation of services such as cardiology, cardiac surgery, and intensive care in many parts of the world has resulted in the need to safely transport children with critical cardiac disease from local hospitals to specialist centres for diagnostic, surgical, and/or critical care intervention. The transport of this cohort of children, whether locally or internationally, can present specific clinical and logistical challenges. An international group of clinicians with expertise in cardiac care and critical care transport worked together to summarise current clinical practice relating to key areas of transport. This expert review covers the transport of the child with critical cardiac disease in terms of referral triage and advice, enabling optimal management of locally available resources, clinical stabilisation before transport, international air transport, transport considerations in low- and middle-income countries, and the transport of children with specific cardiac conditions. As specialist services are centralised to fewer large centres, the need for safe and timely inter-hospital transport of children with critical cardiac disease is only expected to rise in the future. The key principles outlined in this review will be helpful for practitioners in global settings who are, or might be, involved in transporting children between hospitals.

Learning on the fly: How rural junior doctors learn during consultations with retrieval physicians.

OBJECTIVE: This study explores how rural junior doctors learn while consulting retrieval physicians about critically ill and injured patients, as well as the tensions characterising teaching and learning in this setting. METHODS: Data were collected via three focus groups, involving rural junior doctors (n = 8), rural senior doctors (n = 3) and retrievalists (n = 3). The discussions were transcribed and subject to multistage coding. RESULTS: Rural junior doctors believe they learn from interactions with retrieval physicians. Their learning was greatest when the retrieval physician explained his or her clinical reasoning and provided feedback. The level of stress was sometimes overwhelming and learning ceased. Both groups described limited time for teaching due to the medical needs of the patient and the needs of concurrent patients. Retrieval physicians were not certain that rural junior doctors wanted to learn. Rural junior doctors hold retrievalists in very high regard. CONCLUSION: Support provided by retrievalists extends the abilities of the junior doctors and often results in learning. When junior doctors are extended too far, they become overwhelmed and learning ceases. Junior doctors would like the retrievalists to spend more time explaining their actions and providing feedback. Even when both retrievalists and junior doctors are interested in teaching, it may not occur due to misunderstandings and differences in status.

Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport?

INTRODUCTION: Studies show that pediatric trauma centers produce better outcomes and reduced mortality for injured children. Yet, most children do not have timely access to a pediatric trauma center and require stabilization locally with subsequent transfer. Investigators have demonstrated that pediatric transport teams (PTT) improve outcomes for critically ill children; however, these studies did not differentiate outcomes for injured children. It may be that moderate to severely injured children actually fare worse with PTT due to slower transport times inherent to their remote locations and thus delays in important interventions. OBJECTIVE: The purpose of this study was to determine if outcomes for injured children are affected by use of PTT for inter-hospital transfer. METHODS: We conducted a retrospective chart review of 1,177 children transferred to a pediatric trauma center for injury care between March 1st, 2012 and December 31st, 2013. We compared children who were transported by PTT (ground/air) to those transported by ground advanced life support (ALS) and air critical care (ACC). We described patient characteristics and transport times. For PTT vs. ALS and ACC, we compared hospital length of stay (LOS), transport interventions and adverse events. RESULTS: 1,177 injured children were transferred by the following modes: 68% ALS, 13% ACC, 11% Ground PTT, and 9% Air PTT. Children transported by PTT were younger and had higher ISS and lower GCS scores. PTT had a longer total transport time, departure preparation time, and patient bedside time. After controlling for age, ISS, GCS, transport mode, distance, and time, we found no significant difference in LOS between PTT vs. ALS and ACC. A subgroup analysis of children with higher ISS scores demonstrated a 65% longer LOS for children transported by ACC vs. PTT. There were no differences between transport teams with regard to acidosis, hypocarbia or hypercarbia, or maintenance of tubes and lines. CONCLUSIONS: Children transported by PTT were younger and sicker (vs. ACC and ALS). Despite longer transport times, children transported by PTT did not have a longer hospital LOS or adverse events during transport. However, for those children with higher ISS, transport by ACC resulted in longer hospital LOS vs. PTT.

Prehospital transport practices prevalent among patients presenting to the pediatric emergency of a tertiary care hospital.

BACKGROUND AND OBJECTIVES: Prehospital transport practices prevalent among children presenting to the emergency are under-reported. Our objectives were to evaluate the prehospital transport practices prevalent among children presenting to the pediatric emergency and their subsequent clinical course and outcome. METHODS: In this prospective observational study we enrolled all children ≤17 years of age presenting to the pediatric emergency (from January to June 2013) and recorded their demographic data and variables pertaining to prehospital transport practices. Data was entered into Microsoft Excel and analyzed using Stata 11 (StataCorp, College Station, TX, USA). RESULTS: A total of 319 patients presented to the emergency during the study period. Acute gastroenteritis, respiratory tract infection and fever were the most common reasons for presentation to the emergency. Seventy-three (23%) children required admission. Most commonly used public transport was auto-rickshaw (138, 43.5%) and median time taken to reach hospital was 22 min (interquartile range: 5, 720). Twenty-six patients were referred from another health facility. Of these, 25 were transported in ambulance unaccompanied. About 8% (25) of parents reported having difficulties in transporting their child to the hospital and 57% (181) of parents felt fellow passengers and drivers were unhelpful. On post-hoc analysis, only time taken to reach the hospital (30 vs. 20 min; relative risk [95% confidence interval]: 1.02 [1.007, 1.03], P = 0.003) and the illness nature were significant (45% vs. 2.6%; 0.58 [0.50, 0.67], P ≤ 0.0001) on multivariate analysis. CONCLUSIONS: In relation to prehospital transport among pediatric patients we observed that one-quarter of children presenting to the emergency required admission, the auto-rickshaw was the commonest mode of transport and that there is a lack of prior communication before referring patients for further management.

Inter-hospital transfer of ECMO-assisted patients with a portable miniaturized ECMO device: 4 years of experience.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) in patients with severe pulmonary failure is able to keep patients alive until organ regeneration, until shunting out for further diagnostic and therapeutic options or until transportation to specialized centers. Nonetheless, extracorporeal techniques require a high degree of expertise, so that a confinement to specialized centers is meaningful. Following from this requirement, the need for inter-hospital transfer of patients with severely compromised pulmonary function is rising. METHODS: We report about our experience with a portable ECMO system during inter-hospital air or ground transfer of patients with cardiopulmonary failure. RESULTS: The portable ECMO system was used for transportation to the center and in-hospital treatment in 36 patients with an average age of 53 years suffering from respiratory failure. Accordingly, the ECMO system was implanted as a veno-venous extracorporeal system. Pre-ECMO ventilation time was 5.2 (2-9) days. Twelve patients were transported to our institution by ground and 24 patients by air ambulance over a median distance of 46 km. With the assistance of the ECMO device, prompt stabilization of cardiopulmonary function could be achieved in all patients without any technical complications. Post-ECMO ventilation was 9.8 days. Weaning from the ECMO system was successful in 61% of all patients after a median device working period of 12.7 days; median ICU stay was 34 days and a survival rate of 64% of patients was achieved. Technical (8%) and device-associated bleeding (11%)/thromboembolic (8%) complication rates showed very acceptable levels. CONCLUSION: Our experience demonstrates that miniaturized, portable ECMO therapy allows location-independent, out-of-center stabilization of pulmonary compromised patients with consecutive inter-hospital transfer and further in-house treatment, so that sophisticated ECMO therapy can be offered to every patient, even in hospitals with primary healthcare.

Comparison of extracorporeal membrane oxygenation and mechanical ventilation for inter-hospital transport of severe acute respiratory distress syndrome patients / 中华危重病急救医学

Objective To compare inter-hospital transport and clinical outcome in severe acute respiratory distress syndrome(ARDS)patients whom were transported either on extracorporeal membrane oxygenation(ECMO) or on conventional ventilation,and to investigate the optimal means of inter-hospital transport. Methods Eleven patients with severe ARDS who were invalid under conventional ventilation and were transported from other hospitals to Tianjin Third Central Hospital from November 2009 to January 2014 were analyzed. Five patients were transported on ECMO(observation group)and 6 on conventional ventilation(control group). The clinical characteristics,outcomes, transportation,vital signs before and after transportation,respiratory parameters,and Murray score between two groups were compared. Results Patients in observation group were significantly older than those in control group〔years:73(46,77)vs. 34(23,46),Z=-2.293,P=0.022〕. There was no significant difference between observation group and control group in acute pathologic and chronic health evaluationⅡ(APACHEⅡ)score,Murray score,oxygenation index(PaO2/FiO2)before transportation,transit time,and transit distance〔APACHEⅡscore:36(33,39)vs. 27(23,35),Z=-1.830,P=0.067;Murray score:3.5±0.3 vs. 3.4±0.2,t=0.667,P=0.524;PaO2/FiO2(mmHg, 1 mmHg=0.133 kPa):61±14 vs. 63±14,t=-0.249,P=0.809;transit time(minutes):24(18,74)vs. 79(41, 86),Z=-1.654,P=0.098;transit distance(km):12.9(8.3,71.8)vs. 72.4(39.5,86.8),Z=-1.651,P=0.099〕. There was no significant difference between two groups in vital signs and respiratory parameters before transportation. When arrived in ECMO centre,heart rate,respiratory rate,fractional inspired oxygen,inspiratory pressure and Murray score in observation group were significantly lower than those in control group〔heart rate(beat/min):102±16 vs. 136±8, t=-4.374, P=0.002;respiratory rate(beat/min):23±3 vs. 37±2,t=-7.967,P=0.000;fractional inspired oxygen:0.40±0.05 vs. 0.96±0.09,t=-12.152,P=0.000;inspiratory pressure(cmH2O, 1 cmH2O=0.098 kPa):21±1 vs. 34±4,t=-6.887,P=0.000;Murray score:2.7±0.2 vs. 3.8±0.2,t=-8.573, P=0.000〕,but PaO2/FiO2 was higher than that of control group(mmHg:278±65 vs. 41±5 ,t=8.075,P=0.001). Four patients were survived in observation group,and one died from the shortage of oxygen induced lung injury deterioration during transportation. Three patients died in control group,which was directly associated with lung injury deterioration. Conclusion For patients with severe ARDS who need the support of ECMO,ECMO-assisted transfer is safer than conventional ventilation,but transfer should be implemented by experienced team.

First experience with the deltastream(R) DP3 in venovenous extracorporeal membrane oxygenation and air-supported inter-hospital transport.

OBJECTIVES: Based on continuous technical innovations and recent research, extracorporeal membrane oxygenation (ECMO) has become a promising tool in the treatment of patients with acute (cardio)pulmonary failure. Nevertheless, any extracorporeal technique requires a high degree of experience and knowledge, so that a restriction to specialized centres seems to be reasonable. As a consequence of this demand, the need for inter-hospital transfer of patients with severely impaired (cardio)pulmonary function is rising. Unfortunately, most of the ECMO devices used in the clinical setting are not suitable for inter-hospital transport because of their size, weight or complexity. In this article, we describe our first experiences with the airborne transport of 6 patients on a new portable, miniaturized and lightweight extracorporeal circulation system, the Medos deltastream® DP3. METHODS: Six patients suffering acute respiratory failure were taken on venovenous ECMO (DP3) out-of-centre and transferred to the University Medical Center Regensburg by helicopter. All cardiorespiratory-relevant parameters of the patients and the technical functioning of the device were continuously monitored and documented. RESULTS: Implantation of the device and air-supported transport were performed without any technical complications. The patients were transported from a distance of 66-178 km, requiring a time of 40-120 min. With the help of the new deltastream® DP3 ECMO device, a prompt stabilization of the cardiopulmonary function could be achieved in all patients. One patient was under ongoing cardiopulmonary resuscitation by the time our ECMO team arrived at the peripheral hospital and died shortly after arrival in the central emergency ward. CONCLUSIONS: Our experience shows that the deltastream® DP3 is an absolutely reliable and safe ECMO device that could gain growing importance in the field of airborne transportation of patients on ECMO due to its unsophisticated, miniaturized and lightweight characteristics.

Extracorporeal membrane oxygenation support for inter-hospital transport of potential cardiac death donors / 中华器官移植杂志

Objective To discuss Extracorporeal Membrane Oxygenation(ECMO) management method and effect during inter-hospital transport of potential cardiac death donors after cardiac death (DCD).Methods 8 potential donors after cardiac death with brain injury were supported by ECMO for inter-hospital transport.All donors were inserted Medtronic overall cannula into one side femoral artery and venous.The position of catheters were guided by ultrasound.The front-end of venous catheter located in the junction of atrium and inferior vena cava,meanwhile the front-end of artery catheter was below renal artery.100 IU/kg heparin was injected before inserting cannulas.Flow of ECMO maintained at 2.0～3.0 L/min,and oxygen flow was 2～3 L/min during ECMO supporting.When hemodynamics of potential donors were stable,patients were moved into ambulance with ECMO for inter-hospital transport.Results A total of 8 ECMO transports were performed for central circulatory collapse caused brain injury.Patients were previously cannulated and on ECMO prior to transport and transported a distance of more than 100 kilometer from our institution by ambulance.ECMO running times were 120 min,and operation process circulatory stable.Conclusion ECMO can ensure inter-hospital transport of potential donors after cardiac death safety.