Analiza retrospektywna transportu dzieci w stanie zagrożenia życia na terenie województwa mazowieckiego

*Magdalena Mierzewska-Schmidt, Marcin Rawicz

Summary
Background.Safe and effective transport of critically ill children has been considered to be an integral part of pediatric intensive care. Stabilization of the critical patient´s condition before transport, in the field or in the referring hospital, is essential to reduce the incidence of severe complications which may occur en route. The most important components of paediatric transport are the skills and experience of medical and nursing staff and therefore the service should be specialized. Unfortunately, in the Warsaw area, specialized transport for critically ill children is not available.
Methods. The purpose of this study was to retrospectively evaluate the quality of transport of critically ill children (2 months – 15 years) admitted to the pediatric intensive care unit over the period from December 2001 to April 2005. All 66 children required mechanical ventilation during the transfer or immediately after admission.
The severity of illness on admission was evaluated using the PRISM score, and the level of consciousness determined using the GCS. The quality of transport was analyzed using the following factors: maintenance of airway and ventilation, vascular/intraosseous/arterial access, maintenance of circulation (including fluids and drugs), and stabilization of the cervical spine. The primary and secondary (interhospital) transports were compared.
Results. The mean PRISM score was 33.0% ± 23.0. The final mortality rate was 9.1%. 63.6% of children were transported without securing of the airway. 34.2% (25 of 37) of children were intubated at the site of the accident and 41.4% (17 of 29) before the interhospital transfer.
The following complications and/or adverse incidents were observed: traumatic intubation – 2, iatrogenic pneumothorax – 2, accidental extubation – 2, ventilation via the displaced tracheal tube (located in the oesophagus or in the pharynx) – 3, and aspiration pneumonitis – 5. In 4 cases, the size of the tracheal tube was inappropriate. Two children with respiratory distress were transported breathing spontaneously via a tracheal tube (one of them, who was transported over 100 km, subsequently developed ARDS).
25.7% of patients had no vascular access. Peripheral venous access was secured in all children before the secondary transport, whereas only 20 of 37 patients (54%) had an intravenous cannula during the primary transport. Apart from one case of jugular external vein puncture, no attempts at central vessel cannulation were recorded. The intraosseus route was never used.
Intravenous fluids were administered in 30% of cases, usually 3.3% glucose in 0.3% NaCl, and 5% glucose in water or 0.9% NaCl. Colloids or hypertonic solutions were never used. Drugs were given during 56% of all transfers, most frequently sedatives and/or anticonvulsants, and/or steroids. Analgesics were given only once.
Conclusions. The quality of paediatric emergency transport in the Warsaw area has been found to be unsatisfactory. The common practice was „to scoop and run” instead of „stay and stabilize”. There is an urgent need to improve the quality of the transport, either by specialized training of existing teams and/or by organizing a specialized pediatric transportation unit. The latter would be probably more effective.

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