Best Practices for Adult Critical Care Transport
Airway & Breathing
- Secure airway prior to transportation including intubation if appropriate
- Utilize low tidal volume ventilation to minimize lung injury, generally tidal volumes 6-8 ml/kg IBW
- Aim to keep plateau pressures < 32 mmHg
- Maintain pO2 > 60 on < 90% FiO2
- We can consider transporting with inhaled pulmonary vasodilators to improve gas exchange (ex Veletri)
Hemodynamics & Circulation
- Optimize hemodynamics aiming for a MAP > 60mmHg without high dose vasopressor/inotropic support
- If moderate to high dose vaso-inotropic support consider temporary mechanical circulatory support prior to transport
- Attempt correction of significant acid/base derangements to goal pH > 7.2
- Place arterial line for most accurate hemodynamic measurements
- Place central venous catheter if possible for reliable med administration. Minimum of two peripheral IV if central line not placed.
Hematologic
- Mitigate bleeding for goal < 300 cc/hr of acute blood loss
- Transfuse blood products prior to transport if necessary
- Correct significant coagulopathy as able
- Consider if systemic anticoagulation is needed (i.e., Impella), use UFH infusion prior to transfer
Neurologic
- Evidence of neurologic function: able to move all extremities, follow commands
- If GCS is < 8 consider brain imaging to identify neurologic injury
- Minimize sedation as able and utilize opioid infusion as first line for analgo-sedation
ECMO or MCS
- VA ECMO (peripheral): cannulation with 15-17f (LCFA) arterial and 25f (RCFV) venous configuration.
- Ensure adequate distal perfusion by placing 6f reperfusion catheter (arterial cannulation, ipsilateral SFA) at time of cannulation
- Consideration of LV venting with IABP or Impella CP
- VV ECMO: cannulation with 25f (RCFV) inflow and 25f (RIJV) outflow configuration
- XRAY imaging to confirm appropriate cannula positioning. POCUS to evaluate any device alarms as needed.
- Ability to maintain device flow > 2.0 L/min
Communication
- We encourage early referral and are available 24/7 to assist in management and optimization prior to transport
- Report any changes in the patient's clinical status that occur prior to our arrival
- We will provide regular patient follow up and the opportunity to debrief on your patient's clinical course and outcome