The aero-medical transfer of neonates and children

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1 The aero-medical transfer of neonates and children Andrew C Argent Red Cross War Memorial Children s Hospital and University of Cape Town

2 introduction context why transfer neonates and children? are children and neonates different? what are the specific challenges? optimization of the process

3 Land Mass Children worldmapper.com

4 Children Public Health Expenditure worldmapper.com

5

6 what resources should children have?

7 why transport neonates and children? expertise to care for children is severely limited outside of the major centres expertise to care for children is severely limited in Africa many conditions in children that are extremely amenable to therapy are relatively rare and district or regional centres are unlikely to develop adequate experience in management of that condition

8 why transport neonates and children? intensive care effects of regionalization Pollack MM et al, Crit Care Med, 1988 Goh & Lum, Lancet, 2001 Pearson G, Shann F, et al. Lancet, 1997 Pearson et al, Intensive Care Med, patient increase in PICU volume decreased risk adjusted mortality (OR 0.95) and LOS (OR 0.98) Tilford et al, Pediatrics, 2000 cardiac surgery hospitals with <100 cases per annum had higher mortality (8.26% vs 5.95%) surgeons with <75 cases per annum had higher mortality (8.77% vs 5.9%) Hannan et al, Pediatrics, 1998

9 why transport neonates and children? significant reduction in 1 of 2 states where trauma system introduced Hulka et al, J Trauma 1997 children treated at pediatric trauma centre had better outcomes Potoka et al, J Trauma 2000 in Malawi putting children through paediatric emergency had significant benefit Molyneux E,Trans R Soc Trop Med Hyg 2009 Molyneux E et al, Bull World Health Organ 2006

10 neonates and children are different

11 children are different physiology and pathology psychological and support structure the specific problems related to transportation (particularly in the air) the training required by staff in order to provide reliable management reserve, accuracy required, infrequent conditions

12 intravascular volumes total blood volume = 80ml/kg volume for shock = 20ml/kg for 3kg infant 240ml = total blood volume for 6m infant 340ml = total blood volume

13 flow through tubes 1 1 ml/ min 2 16 ml/min 4 256ml/min Pressure difference for each tube is 100 mmhg

14 laryngeal anatomy Todres et al, Pediatric Anaesthesia

15 concerns airway and ventilation temperature and metabolic noise vibration

16 Benumof et al, Anaesthesiology, 1997 derived from Farmery and Roe, Br J Anaesthesia,1996

17 Alveolar po2 100mm Hg 80mmHg 60mmHg Sands et al, PLOS, 2009

18 concerns in the transport environment noise average noise in incubator in aircraft close to 80dB (proposed limits in NICU 45dB) Sittig et al, Int J Pediatr Otorhinolaryngol, 2011 physical stressors including vibration Bouchut et al, Air Med J, 2011

19 Bouchut et al, Air Med J, 2011

20 training for staff specific skills related to age-group anaesthesia airways ventilation vascular access simulation training for environmental awareness for group dynamics and training crew resource management

21 training and EMS for children pediatric pre-hospital advanced life support care in an urban setting. 50 ALS providers in the EMS system averaged: pediatric IV cannulation 3.7 times intubation 0.3 times, intraosseous access 0.06 times per provider per year Babl F et al, Pediatr Emerg Care, 2001 retrospective review of pre hospital airway management 34% intubation failure rate in children vs 9.8% in adults Boswell WC et al, Air Med J 1995

22 communication 24% problems preventable by improved education of referring doctors; 28% problems preventable by better transport service organization 5% related to conditions of transport. Henning R, McNamara V. Pediatr Emerg Care 1991 characteristics of the medical team at the referral hospital have a substantial impact on the nature of intervention that is performed by the transport team. Kronick JB, et al. Pediatr Emerg Care 1996

23 quality control in a service Ramnarayan et al, Arch Dis Child, 2009

24 Ramnarayan et al, Arch Dis Child, 2009

25 Abdel-Latif and Berry, Arch Dis Child, 2009

26 Abdel-Latif and Berry, Arch Dis Child, 2009

27 accreditation of services aviation issues dedicated crew specific measures to reduce accidents related to air mercy flights medical team issues training certification recertification (aircraft related)

28 factors to be discussed public versus private services human factors fatigue, competition pressures on pilots; training SMS and risk analysis dispatch procedures; technologies. NTSB HEMS public hearings 2009

29 accidents and flying Between 1980 and 2008, HEMS fatalities occurred in the United States involving: 223 crew members, 34 patients, and 5 other individuals. In 2008 alone, 15 HEMS accidents, with 29 fatalities, occurred. A review of all HEMS accidents from 1983 to 2005 showed that 395 of them were fatal. Comparing medical versus nonmedical fixed-wing flights, medical flights made up only 0.09% (59/59,040) of all aviation accidents in this database. However, the fatal outcomes were significantly higher in medical flights (35.6% vs. 19.7%), with more aircraft fires (20.3 vs. 10.5%) and on-ground collisions (5.1% vs. 2.0%) Handel and Yackel, Air Medical Journal, 2011

30 conclusions there is a clear need for air transport of sick neonates and children with measurable benefits development of the services should be incorporated into the development and planning of regional paediatric services specific measures must be taken to train and certify crew used on these services

31 conclusions for the neonates and children transfers are longer in smaller infants different skills are required and there is overwhelming evidence that specialist teams have better outcomes there are specific areas of concern including noise environment pressure environment vibration and motion during the transport

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