Key points
Critical events occur in about 5% of urgent air-medical transports, most often hemodynamic deterioration. Infusion pumps drift from their set rate under the conditions transport imposes: altitude, vibration, vertical displacement and back-pressure. A standardized changeover technique and consistent patient monitoring are essential to patient safety and target outcomes.
You are ten minutes into a ninety-minute rotor-wing interfacility transfer. Your patient is a 74-year-old man with septic shock from a perforated diverticulum, intubated, on norepinephrine at 0.18 mcg/kg/min through a right internal jugular triple-lumen. Your patient was stable on the sending unit's pump. Now your monitor shows a MAP of 52. The pump face says the drug is running. The line is patent. Nothing has been titrated. Nothing has alarmed. And the patient is deteriorating anyway.
Critical care transport requires a continuous effort to detect and minimize risk to patient and crew, while operating in a dynamic environment. In our scenario, the pump is performing as programmed – yet our patient is losing blood pressure. Why? In part, because the programmed “rate” is a statement about a motor, not a promise of what reaches the catheter tip and vasculature. The distance between the pump and the patient circulatory system, in a moving aircraft or ground transport, is where critical care patients can be at risk.
We must start with a basic foundational maxim. Patients who don’t need to be transported, should not be transported. Meaning, that if a critical care patient is in transport, it is for one of a few reasons: 1) acuity, level of care or clinical care needs are not available at the current facility and transport to a higher-level care setting is necessary or 2) the patient or family has requested transport to another facility. Otherwise, there would be no reason to risk patient, crew and outcome with a patient that is critical.