Equipment

The essential features of equipment used in neonatal-pediatric transport are listed in Table 6.1, and a specific equipment list is shown in Table 6.2. Packs may need to be tailored to the needs of the individual transport service, and all team members should be facile in locating all supplies.

Various transport incubators (eg, Isolette [Draeger Medical Inc, Telford, PA]) are available commercially. The type selected must provide regulated temperature, oxygen, and humidity and allow visibility and easy emergency access to the infant during transport. Transport incubators can be assembled in many different configurations for a multitude of transport vehicles. Often, incubator design will allow for the internal mounting of monitors and venti­lators. Review and approval of the FAA are required if the incubator is to be used on rotor- or fixed-wing aircraft.

The choice of ventilators requires careful consideration and should be based on projected use, cost, team skill level, and team configuration to ensure proper operation. The availability of a respiratory therapist may influence the range of ventilator options during transport. Modes of ven­tilation for infants and children range from pressure-limited, time-cycled to volume-cycled or flow-triggered pressure support. Most ventilators are

Table 6.1: Essential Features of Equipment Used in Neonatal-Pediatric Transport

• Lightweight and portable

• Durable, able to withstand 4g acceleration and deceleration forces

• Easily maintained and cleaned

• Portable power (twice the expected mission time as minimum)

• AC/DC capable (use vehicle or hospital power source when possible)

• Production of no electromagnetic interference

• Resistant to electromagnetic interference

• Well-labeled (including return address of transport team)

• Audible and visible alarms

• Completely securable

• Compatible with all other equipment

• Able to meet all local, federal, state, and Federal Aviation Administration codes, including hazardous material regulations

• Able to tolerate altitude and temperature changes, sudden decompression, and vibration without performance change

• Able to fit easily through standard hospital doors and doors of transport vehicles

• Loadable in vehicles by 2 transport personnel

Table 6.2: Specific Equipment Used in Neonatal-Pediatric Transport*

• Transport incubator (patients functions and can be adjusted for use with patients ranging from neonates to adults; other ventilators are ideally suited to a more limited patient population.

As the use of cuffed airway devices becomes more prevalent in both neonatal and pediatric populations, the risks associated with tracheal mucosa damage should be proactively managed by monitoring and adjusting tracheal cuff pressures during the transport process. Because gases in enclosed spaces will expand with decreases in ambient barometric pressure (increas­ing altitude), the intracuff pressures of airway devices should be monitored and adjusted routinely throughout both rotor- and fixed-wing transports. Consideration for the use of incompressible fluids, such as saline, could be considered to avoid excessive intracuff pressure changes during air trans­ports, but further research is warranted.

In addition to traditional laryngoscopy equipment, video-assisted intubation devices have gained increasing popularity in the management of difficult airways in the neonatal and pediatric transport environments.

The use of inhaled nitric oxide to treat severe, persistent pulmonary hypertension in term and near-term neonates is standard of care. Teams transporting neonates receiving inhaled nitric oxide require specialized personnel and delivery devices to provide the correct mixture of gases through transport ventilators. The use of inhaled nitric oxide during trans­port is not recommended until transport personnel are well trained with the equipment in the intensive care setting.

It is standard for infants and children to have end-tidal CO₂ moni­tored during assisted ventilation via an endotracheal tube during transport. Disposable end-tidal CO₂ detectors are available commercially in several sizes for use in patients ranging from infants (>2 kg) to adults. These colo­rimetric detectors are light-and moisture-sensitive and are most commonly used to confirm tracheal tube placement at the time of intubation rather than to monitor tracheal tube position during transport. Capnography dur­ing transport is available with a portable device or as a built-in component of a transport monitor. The advantage of end-tidal CO₂ monitoring, as opposed to detection, is the continuous graphic display of each respiratory cycle. In addition to the ongoing confirmation of endotracheal tube posi­tion, capnography can provide valuable information about ventilation and circulation when interpreted by knowledgeable providers. It should be noted that the efficacy of these monitors and detectors has not been tested as thor­oughly with neonates, especially those who are preterm, compared with children and adults.

Oxygen and air cylinders must be labeled and checked regularly. A desirable supply estimate is based on at least double the anticipated needs for the transport. A portable supply must be available for the transfer of the patient to and from the transport vehicle, with appropriate tubing lengths for maneuvering equipment in and out of ambulances and aircraft. Oxygen and air connection adapters can be carried by the transport team and used to connect the transport equipment to various types of oxygen and air outlets at referral facilities to prevent depleting transport gas cylinders. It is essential to be able to provide oxygen concentrations between 21% and 100% during interfacility transport, especially for infants with congenital heart disease who are at risk of pulmonary overcirculation in the presence of high con­centrations of oxygen. Certain air-oxygen blenders are less wasteful of gases than others, and the most efficient gas-conserving model should be selected. Monitoring of the delivered oxygen concentration also is required.

Suction capability in all aspects of transport is essential. Whether it is for airway clearance or for thoracostomy tube drains, a stand-alone, battery- powered unit is required. The ability to regulate vacuum pressure is essential for the neonatal population. Additionally, many state ambulance licensing agencies require mounted suction units in all transport vehicles.

Many cardiovascular and vital sign monitors are available commercially. Multifunction monitors that include oximetry and invasive and noninvasive blood pressure monitoring are desirable but can be costly. For noninvasive blood pressure monitoring, appropriate cuff sizes for a variety of patients must be available.

Pulse oximeters used in aircraft must pass electromagnetic interference testing. Pulse synchronization is essential to avoid erroneous readings during transport, when patient movements and vibration may interfere with optimal operations. A secondary pulse oximeter should be considered if the continu­ous monitoring of both pre- and postductal oxygen saturations is needed for the monitoring of suspected cardiac defects.

Monitoring of patients' temperature is mandatory. Hypothermia and hyperthermia are common findings in pediatric patients (eg, prematurity, sepsis, cold-water drowning, and febrile seizures). Hypothermia may result from the exposure involved in stabilization and transport, especially in pre­term neonates. Personnel should be familiar with the myriad of skin and tympanic membrane probes available for transport.

Intravenous infusion pumps must have stand-alone capability and be capable of accurate, controlled, and even delivery of infusion fluids and medications through various intravenous and umbilical line apparatus. Battery-operated pumps that can deliver rates as low as 0.1 mL/hour, and high-flow rates may be required and are readily available commercially. Transport teams should use pumps that can be secured safely on intravenous poles attached to transport stretchers or incubators so that they do not have to be carried separately.

Blood glucose monitoring strips or portable glucometers are essen­tial during transport. Many teams now use point-of-care portable testing equipment, which allows for accurate electrolyte and/or blood gas measure­ments. Portable blood gas analyzers are also commercially available. When considering whether to provide point-of-care testing, a transport program should be aware that there are considerable requirements for quality con­trol and documentation in conjunction with the sponsoring institution's laboratory services.

A separate, designated pediatric defibrillator-cardioverter/pacer is highly recommended and may be required for transport vehicle state licensure, but it might not be used during most transports because of the low incidence of arrhythmias in the neonatal and pediatric age groups. Each team must con­sider the weight and cost of such equipment versus the realistic needs on the basis of the patient population, thereby potentially making the routine inclu­sion of this equipment less practical for some exclusively neonatal transport teams.

The use of intracranial pressure monitoring during neonatal-pediatric transport may also be encountered. Specific training and equipment are needed to optimally manage the care of patients who need such monitoring.

Medications

Table 6.3 lists the basic groups of medications and intravenous fluids used by neonatal-pediatric transport teams. Important indications, contraindications, and special considerations for administering neonatal-pediatric transport drugs are accessible via local, published, and online formularies. A sample transport team drug dosage card is included in Appendix B.

Medications need to be checked and restocked routinely before and after every transport and their use needs to be logged appropriately. A routine and scheduled inspection for expired medications and a rotation plan for near-expired medications are recommended. Transport medications should be stored in a secure, safe, dedicated place between transports so they are not depleted inadvertently by use in another clinical area. Transport teams should always assume that community hospitals will not have the medica­tions or specialized fluids needed to treat most neonatal and pediatric con­ditions. Any incorrect dose or unexpected adverse drug reaction should be

Table 6.3: Basic Groups of Medications and Intravenous Fluids Used by Neonatal-Pediatric Transport Teams

• Intravenous fluids

— Dextrose 10% in water (DιoW), dextrose 5% in water (DsW), dextrose 5% in 0.22% normal saline (D5W 0.2

NS), dextrose 5% in 0.45% normal saline (D5W 0.45 NS), lactated Ringer's, normal saline (NS), albumin 5%

• Inotropic agents

— Dopamine, dobutamine, epinephrine, norepinephrine, milrinone

• Code medications

— Epinephrine, sodium bicarbonate (infant and adult preparations), naloxone, lidocaine, amiodarone, atropine, adenosine, calcium chloride, calcium gluconate, magnesium sulfate

• Rapid-sequence intubation medications

— Fentanyl, midazolam, ketamine, etomidate, thiopental, rocuronium, vecuronium, succinylcholine, atropine

• Diuretics: furosemide

• Antibiotics

— Ampicillin, gentamicin, cefotaxime, ceftriaxone, cefazolin, acyclovir

• Prostaglandins

• Surfactant preparations

• Asthma and croup medications

— Methylprednisolone, dexamethasone, racemic epinephrine, albuterol, terbutaline, ipratropium

• Anticonvulsants

— Lorazepam, phenobarbital, fosphenytoin

• Intracranial pressure medications

— Mannitol, dexamethasone, hypertonic saline

documented and reviewed with the team's medical director and the pharma­cist immediately following the transport.

Most analgesics, sedatives, and induction agents are considered con­trolled substances by state and federal agencies. All controlled substances must be prescribed by a physician with a valid US Drug Enforcement Agency license and state controlled substance certificate. For a nonphysician trans­port team, orders for controlled substances must be signed by the medical control physician or appropriate designee. For hospital-based transport teams, institutional policies govern the documentation requirements for controlled substances and the process for replenishing supplies after use. For freestanding transport teams, an arrangement with one or more medi­cal control facilities should be made to provide replacement of controlled substances through a hospital pharmacy. State ambulance licensing agencies may require a designated, locked compartment on the transport vehicle for securing narcotic medications.

The use of endotracheally administered surfactant for neonates with respiratory distress syndrome is standard of care in the neonatal ICU. Many transport teams or referring medical teams administer surfactant to appro­priate patients at referring nurseries before transport to the tertiary center. It is highly recommended that each team standardize its surfactant protocol and be well trained in its administration to minimize confusion and potential adverse effects, such as accidental extubation, pneumothorax, and pulmonary hemorrhage. Lung compliance changes should be anticipated during the first 30 minutes following surfactant administration. Some transport teams wait a specified time after administering surfactant to initiate the return transport.

Drug packs optimally should be constituted according to the needs of an individual team. Because most drugs used in pediatrics are given on a dose-per-kilogram basis and the weight of some critically ill pediatric patients may not be available at the time of transport, it is recommended that a length-based tape or length-weight or weight-for-age chart be used to approximate the child's weight. This chart can be used for emergency drug and fluid calculations until a definitive weight can be obtained. Teams that use length-based tapes on which doses are provided in milliliters should ascertain that the concentration of the drug preparation used matches that used on the tape.

Weight-drug-dose tables should be attached to drug packs and intake sheets to facilitate efficient mixing and administration of drugs (eg, vaso­pressors, antibiotics, and medications used during cardiopulmonary resuscitation). Drug cards, developed by each team, may be laminated and pocket-sized and should include important telephone numbers.